Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve repeat MBBs. You say that the enrollee requires these injections to improve 
their condition. The Plan denied your request. The Plan says that the enrollee did not have 80% relief from the 
previous injections. 
 
The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary after the first diagnostic facet joint procedure, 
there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of 
relief being consistent with the agent used). 
 
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 repeat MBBs. Our reviewer says that 
repeat MBBs are medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee had 80% pain relief and 50% improvement in function for a few hours. Therefore, the reviewer found 
that the request for repeat MBBs is medically 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 repeat MBBs have been met. Therefore, we decided that the Plan has to pre-
approve repeat medial branch blocks (MBBs).  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnosis evaluation and psychotherapy 
provided from September 13, 2022, to November 30, 2022. 
 
You asked the Plan to pay for the psychiatric diagnosis evaluation and psychotherapy. The Plan denied your 
request. The Plan says this type of provider is not part of the Medicare Program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnosis evaluation and 
psychotherapy provided from September 13, 2022, to November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 14, 2019. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says medical records were not provided 
to review for hospital audit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services provided 
have been met. Specifically, complete medical records have not been provided for review. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services provided on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's greatest chance for 
recovery and return to their previous lifestyle are dependent on their ability to move to the LTACH where early 
mobility and increased physical therapy can be facilitated. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are not services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable and as it would not be clinically advantageous. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 8, 
2022, through March 11, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says observation level of care was more appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee appeared stable and was not expected to require hospital care that would 
likely cross two (2) midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 8, 2022, through March 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 24, 
2022, through June 25, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care (including earlier 
emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from June 24, 2022, through June 25, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found per records the Plan has accurately described the enrollee's variable capacity or 
interest in therapy and reduced capacity to participate in daily therapy. No daily skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and a 
wheelchair component or accessory, not otherwise specified (K0108). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and accessory. You say that the enrollee has 
been using a manual wheelchair since his injury. Due to his previous chairs being out of commission, the 
enrollee would be immobile if something were to happen to his current chair. He needs a new manual 
wheelchair to ensure mobility security and his daily life maintains appropriate quality and to fulfill all ADLs. 
The Plan denied your request. The Plan says the records received do not show irreparable damage to the 
enrollee's current wheelchair such as from a specific accident or from a natural disaster. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 The file shows that the enrollee received a manual wheelchair in November 2020. The manual wheelchair 
serves the same purpose as an ultralightweight wheelchair and accessory. Therefore, we decided that the Plan 
does not have to pre-approve an ultralightweight wheelchair (K0005) and a wheelchair component or 
accessory, not otherwise specified (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cluneal nerve block. 
 
You asked the Plan to pre-approve a cluneal nerve block. You say that a cluneal nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested cluneal nerve block is 
experimental/investigational. 
 
The Plan follows Medicare rules. 
 
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 cluneal nerve block. Our reviewer 
says that a cluneal nerve block is not considered medically necessary in this case. Our physician reviewer 
found according to the criteria, the use of nerve blocks with or without the use of electrostimulation, and the 
use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by 
underlying systemic diseases, are not considered medically reasonable and necessary. At present, the literature 
and scientific evidence supporting the use of peripheral nerve blocks with or without the use of 
electrostimulation/electromagnetic stimulation, and the use of electrostimulation/ electromagnetic stimulation 
alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is insufficient to 
warrant coverage. These procedures are considered investigational and are not eligible for coverage for the 
treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. Cuneal nerve blocks are used as a proposed treatment for individuals with cluneal nerve entrapment syndromes 
causing pain in the low back and buttocks. The superior and the middle cluneal nerves (SCN and MCN) are 
cutaneous nerves that are sensory and dominate sensation in the lumbar area and the buttocks, and entrapment 
of these nerves around the iliac crest can elicit low back pain. Although the etiology of SCN entrapment 
neuropathy remains unclear, the symptoms are low-back pain (buttock pain) and paresthesia in the area of SCN 
innervations. The block is intended to interrupt the conduction of pain impulses and minimize the neuropathic 
pain and paresthesia associated with the SCN entrapment. Cluneal nerve injections are considered 
investigational and/or unproven. The review has determined that the requested cluneal nerve block does not 
meet the Medicare LCD coverage criteria. 
 
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 cluneal nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cluneal nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare for LTACH 
care that cannot be accomplished at a lower level of care. You would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have swollen, sore, painful feet and weakness. 
You say you have nine steps into your home that you would not be able to do at this time. The Plan denied your 
request. The Plan says the request for SNF services is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate. 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of prostate is covered 
for certain indications. 
 
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 transurethral waterjet ablation of 
prostate. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found you have benign prostatic hyperplasia and lower urinary 
tract symptoms. Peak flow is 5.7 mL/s. Prostate volume was 63 grams on ultrasound. Prostate-specific antigen 
on December 6, 2022, was 15.03 ng/mL. Aquablation has not been approved for use in enrollees with prostate 
cancer. The records show that you have prostate cancer. Therefore, you do not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you need an oxygen tank because you 
have been in the hospital multiple times due to low oxygen. You are requesting to have an oxygen tank for 
personal use to prevent hospital admissions. The Plan denied your request. The Plan says the notes do not show 
that your provider has filled out and submitted a certificate of medical necessity for you to use oxygen at home. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 
 
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator (E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that bilevel positive airway pressure machines do not 
have the needed modes. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose and a bilevel positive airway pressure device could meet the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a synthetic sheepskin pad (E0188) and dynamic 
adjustable wrist extension and flexion device, includes soft interface material (E1805). 
 
You asked the Plan to pre-approve the durable medical equipment. You say that the enrollee does not have use 
of their hand. The Plan denied your request. The Plan says the requested items are not covered benefits.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say continuous passive motion devices are covered for patients who have 
received a total knee replacement. 
 
The sheepskin pad at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 
is available to the general public and would be helpful even to those who are not sick or injured. Additionally, 
continuous passive motion device is not a covered benefit for wrist pain. Therefore, we decided that the Plan 
does not have to pre-approve a synthetic sheepskin pad (E0188) and dynamic adjustable wrist extension and 
flexion device, includes soft interface material (E1805).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on June 15, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for wound care provided on June 15, 2022, by an out-
of-network (OON) provider.