Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the admission to an IRF is not medically necessary. 
 
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 that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM sensor. You say that the requested CGM is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
requested CGM sensor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 CGM sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spinal Simplicity interspinous-interlaminar fusion 
device (Minuteman device). 
 
You asked the Plan to pre-approve the Minuteman device. You say that the Minuteman device is medically 
necessary. The Plan denied your request. The Plan says he Minuteman device 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 pre-approve the Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the Minuteman device is experimental. More research is needed. 
 
 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
  You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the Plan 
requires a trial of an oral bisphosphonate and injectable bisphosphonate before they will approve the requested 
drug. Our physician reviewer found that the enrollee has not tried and failed the required drugs. There is no 
documentation provided indicating that the Plan's required drugs would likely be less effective or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 6, 2022, to 
November 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the delay in the certification 
information caused the NOA to be submitted late. The Plan denied your request. The Plan says the NOA was 
not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
The records show you were notified that your change of ownership was approved before the start of care date. 
In this case, the start of care date is October 6, 2022. The NOA was not received by the Plan until December 6, 
2022. As more than 30 days passed since the timely filing date and the NOA receipt, no payment can be made 
on this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from October 6, 2022, to November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DTRAX facet fusion posterior instrumentation device 
(22842). 
 
You asked the Plan to pre-approve DTRAX facet fusion posterior instrumentation device. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
requested service in the setting of posterior cervical spine fusion surgery have not been demonstrated in the 
peer-reviewed literature. There is no documentation the enrollee is participating in a clinical trial or study.  

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 DTRAX facet fusion posterior 
instrumentation device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. Further studies are required to demonstrate the safety and efficacy of the requested posterior 
instrumentation device. Additionally, the fusion approved was for a posterior spinal fusion and no indication 
for addition of an anterior fusion for which the device could potentially be supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DTRAX facet fusion posterior instrumentation device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve DTRAX facet fusion posterior 
instrumentation device (22842).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex superion interspinosu spacer. 
 
You asked the Plan to pre-approve a vertiflex superion interspinosu spacer. You say that the enrollee's pain has 
not responded adequately to physical therapy, injections, and pain medications. The Plan denied your request. 
The Plan says this device has not been shown to be safe and effective for treatment of the enrollee's condition. 
 
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 a vertiflex superion interspinosu spacer. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the vertiflex superion interspinosu spacer is experimental and more 
research is needed. 
 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 vertiflex superion interspinosu spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a vertiflex superion interspinosu spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty at L1 (22511). 
 
You asked the Plan to pre-approve a percutaneous vertebroplasty. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says this procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVP is covered when all the criteria listed in the 
Medicare rules section are met. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the records do not 
show at fracture at L1. Sacroplasty is experimental for sacral insufficiency lesions. 
 
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 percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebroplasty at L1 (22511).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the lumbar arthrodesis 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 pre-approve the Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that current medical guidelines and peer-reviewed literature do not support 
the interspinous fusion device procedure over the standard lumbar fusion. In addition, there are multiple 
alternate pain generators contributing to the clinical condition that have not been fully documented as having 
been ruled out. There is no rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has low 
back pain and radicular symptoms. The enrollee has completed 6 weeks of physical therapy and has had some 
improvement but still has pain and leg weakness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of magnetic resonance imaging (MRI) have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing for the F2 (prothrombin, coagulation factor II) 
gene (81240). 
 
You asked the Plan to pre-approve F2 gene testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this service is not considered medically necessary by Medicare rules and 
cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that items and services that 
are not medically necessary are not covered. The rules say that testing for the F2 gene is not considered 
clinically efficacious, and therefore is not medically necessary. We looked at the file and Medicare rules. The requested test is not covered by Medicare as it is considered to 
not be clinically efficacious and therefore is not medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve testing for the F2 (prothrombin, coagulation factor II) gene (81240).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 7, 2022, to 
November 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be reprocessed 
due to no definitive reason for denial. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 7, 2022. The NOA was not received by the Plan until December 
21, 2022. As more than 30 days passed since the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from October 7, 2022, to November 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical record clearly documents that this enrollee does not meet evidence-based 
criteria. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet coverage criteria. Our physician reviewer found detailed documentation is not evident 
regarding any hospitalizations or moderate/severe pain levels. Additionally, the pain is not worsening, and the 
documentation does not support progression of the vertebral height loss, kyphotic deformity, or a severe impact 
on the enrollee's daily functioning directly related to the vertebral compression fracture. Moreover, plausible 
other causes of the enrollee's low back pain are evident on the provided MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) and a pontic (D6245). 
 
You asked the Plan to pre-approve D6740 and D6245. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says documentation did not include a physical or neurological disorder 
that precludes the use of a removable prosthesis. 
 
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 D6740 and 
D6245 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 D6740 and D6245. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found the Plan states "the placement of 
a fixed prosthetic appliance will only be considered for those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis." In this instance 
there is no documentation that supports any condition of physical or neurological compromise. 
 
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 D6740 and D6245 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a retainer crown (D6740) and a pontic (D6245).
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 you need rehabilitation to get strength up to get back 
to the way you were. The Plan denied your request. The Plan says your records do not show that you need an 
intensive team for your care. Services needed may be provided safely in 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 your 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee's records do not show the need for continued 
treatments and care that can only be given in a hospital setting. When ready to leave the hospital, services 
needed may be provided safely in a lower level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) hours a day of home health aide 
services.  
You asked the Plan to pre-approve additional aide services. You say that the enrollee is in need of 24-hour care. 
35 hours per week is not sufficient for the enrollee's needs. The Plan denied your request. The Plan says 
Medicare can only cover 35 hours a week of home health services. 
 
The Plan must follow Medicare rules. The rules say to be covered under the home health care benefit, your 
skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per 
week.  
 
We looked at the file and Medicare rules. The records show you are currently approved for visits up to 35 hours 
a week for home health aide services. Additional hours are not a covered benefit. The total combined hours you 
receive from home health aide services must not be more than the most that can be approved by Medicare. 
Based on this information, we decided that Medicare rules for coverage of additional aide services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) hours a day of 
home health aide services.