Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural. You 
say that this is medically necessary. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show failure of improvement with two different SCS implants. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve percutaneous implantation of 
neurostimulator electrode array, epidural. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found this request exceeds 
that limit and is therefore deemed, not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural have not 
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array, epidural (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has severe COPD, and 
the hospital is not letting them go home without the trilogy because of they fear the enrollee will have life 
emergencies without it. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this patient because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease and obesity 
hypoventilation syndrome. However, the documentation does not contain sufficient information in the medical 
records to justify the treatment selected. The records indicates that the enrollee was successfully treated with 
BiPAP and could be treated with a BiPAP machine with AVAPS capabilities, and failure of such a device has 
not been documented. Therefore, the elements of the coverage criteria are not satisfied, and the requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has a medical necessity for an IRF 
admission. The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF 
admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided at a 
different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant removal (D6100) for tooth #3 and #5, 
the surgical removal of an erupted tooth (D7210) for tooth #23, #24, and #25, and sedation (D9248). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the dental services to be 
approved and paid for. The Plan denied your request. The Plan says the denial of authorization for the surgical 
removal of an erupted tooth is correct because documentation does not support removal of bone. Also, the 
dental implant removal and the sedation are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the surgical removal of an erupted tooth for tooth #23, #24, and #25 is not medically necessary. Our 
physician reviewer found that surgical extractions require that bone be removed in order to remove the tooth 
from the dental arch. Where there is remaining coronal tooth structure the need for surgical extraction is not 
clear, and the determination for the need would be following the attempted removal of the noted tooth, with 
elevation and forceps removal being the primary attempt. If the need arises for removal of bone to complete the 
extraction, then a claim may be submitted with support from clinical documentation for the necessary 
procedure. At the present time, a surgical extraction is not clearly necessary given the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical removal of erupted tooth have not been met. The dental implant 
removal and the sedation are not covered under the Plans dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve a dental implant removal (D6100) for tooth #3 and #5, the surgical removal of an 
erupted tooth (D7210) for tooth #23, #24, and #25, and sedation (D9248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee has a neurological condition. You say that the therapy team is unable to effectively pressure relieve, 
putting the enrollee at an increased risk for skin breakdown. You also say that the enrollee meets all the 
medical requirements for the requested power wheelchair. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for multiple power options included in the requested power wheelchair.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided records do not support that the 
enrollee is high risk for skin breakdown and is unable to perform a functional weight shift, has a history of 
pressure ulcer(s) or has had skin flap surgery. The records do not document the enrollee performs bladder self-
catheterization or that they require the tilt/recline to manage increased muscle tone or spasticity to meet criteria 
for the power tilt and/or recline and thus the multiple power option base. Therefore, the reviewer found that the 
requested Group 3 power wheelchair with multiple power options is not medically reasonable or necessary. 
The reviewer also found that since the requested wheelchair base does not meet Medicare coverage criteria, the 
requested accessories are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve placement of a CardioMEMS device. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of a CardioMEMS device. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a CardioMEMS device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of a CardioMEMS device (33289, C2624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation shows that the enrollee is ambulating 200ft without assistive device while continuing to have 
pain. Their limited range of motion no longer shows that enrollee is home bound thus the records do not show 
that 8 additional home health physical therapy visits are required to effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is needed for the enrollee to 
determine proper treatment. The Plan denied your request. The Plan says the enrollee's condition does not meet 
all of the requirements for inpatient rehabilitation admission. The Plan says services may be provided at a 
lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has had prior brain radiation therapy, and the requested services 
would constitute re-irradiation, for which proton therapy can be considered necessary in select situations. The 
requested services, particularly in the setting of re-irradiation, can be considered an accepted standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have been met. Therefore, we decided that the 
Plan has to pre-approve proton beam radiation therapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (99204) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a consultation with an out-of-network provider. You say that you want the 
Plan to approve this service. The Plan denied your request. The Plan says the service is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation (99204) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction device (E0849) provided on May 9, 2023. 
 
You asked the Plan to pay for the device. You say that this is needed to help assist with mobility. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the physician documentation does not reveal that the enrollee has had appropriate use of a home 
cervical traction device and the patient tolerated the selected device. The documentation does not support that 
the patient has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment for the 
TMJ condition; or,  has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a 
chin halter is unable to be utilized; or, that the treating practitioner orders and/or documents the 
medical  necessity for greater than 20 pounds of cervical traction in the home setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pay for a cervical traction device (E0849) provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve definitive drug testing for 15-21 22 drug classes. 
 
You asked the Plan to pre-approve definitive drug testing for 15-21 22 drug classes. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that criteria to establish medical necessity for drug testing 
must be based on patient-specific elements identified during the clinical assessment, and documented by the 
clinician in the patients medical record and minimally include certain elements. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve definitive drug testing for 15-21 22 
drug classes. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there do not appear to be any evidence to support medical necessity for definitive urine drug testing on this 
enrollee. She is on a stable pain management regiment and notes do not indicate any issues with adherence or 
diversion to suggest a need to monitor her urine results other than a qualitative test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive drug testing for 15-21 22 drug classes have not been met. Therefore, 
we decided that the Plan does not have to pre-approve definitive drug testing for 15-21 22 drug classes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Sprint peripheral nerve stimulation 
(PNS) device. 
 You asked the Plan to pre-approve a Sprint PNS device. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a 
Sprint peripheral nerve stimulation (PNS) device.