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

 
We decided that the Plan does not have to pay for the outpatient surgery provided on May 04, 2023. 
 
You asked the Plan to pay for the outpatient surgery. You say that you were unaware that authorization was 
needed. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the outpatient surgery 
provided on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of posterior tibial neurostimulation 
(PTNS). 
 
You asked the Plan to pre-approve PTNS. You say that it is medically necessary. The Plan denied your request. 
The Plan says the requested service does not meet the requirements for approval. 
 
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 PTNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PTNS is not indicated for patients with neurogenic bladder as is the case here. PTNS is 
indicated for patients with non-neurogenic overactive bladder. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the continuation of posterior tibial neurostimulation (PTNS).
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 these services so that you can get back to 
normal. The Plan denied your request. The Plan says the required services you need can be provided in an 
alternate setting  
 
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 your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies. 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 you 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 inpatient rehabilitation facility (IRF) admission and 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 the inpatient rehabilitation facility is the most 
appropriate level of care for the enrollee. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility services are 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 The complexity of the enrollee's nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
that an MRI of the lumbar spine is not medically necessary.  
 
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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is medically necessary. Our physician reviewer found that the 
prior positive lumbar spine x-rays, continued symptoms without improvement after medication, and home 
exercise program provide evidence of medical necessity of an MRI of the lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. You say that the enrollee is having sacroiliac joint pain and 
has tried Tylenol, Ibuprofen, ice heat and Decadron without any improvement. The Plan denied your request. 
The Plan says a sacroiliac joint injection 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 injection. Our reviewer says that a 
sacroiliac joint injection is not medically necessary. Our physician reviewer found that the enrollee was seen on 
September 22, 2023, however there was no follow up after being given Medrol dose pack. Also, there were no 
imaging done of the lumbar spine or sacroiliac joints. Therefore, the medical necessity with a stated history of 
2-3 weeks of sacroiliac joint pain has not been established in the submitted records. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity joint. 
 
You asked the Plan to pre-approve an MRI of the lower extremity joint. You say that the enrollee's left 
shoulder pain has gotten worse and more painful. The Plan denied your request. The Plan says an MRI of the 
lower extremity joint is not medically necessary. 
 
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 an MRI of the lower extremity joint. 
Our reviewer says that an MRI of the lower extremity joint is not medically necessary. Our physician reviewer 
found that while there are no red flags the plan is for physical therapy. Also, the medical necessity of an MRI 
of the left shoulder is not documented in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI of the lower extremity joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the intracept basivertebral nerve ablation. You say that the enrollee's pain is 
disabling and affects their quality of life. The Plan denied your request. The Plan says the intracept 
basivertebral nerve ablation 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 intracept basivertebral nerve 
ablation. Our reviewer says that the intracept basivertebral nerve ablation is not medically necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without facet degenerative joint disease or stenosis. Therefore, the coverage criteria have not been met as the 
cause of pain is not clear.  
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 intracept basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the intracept basivertebral nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neuromonitoring provided on May 17, 2023. 
 
You asked the Plan to pay for intraoperative neuromonitoring. You say that it is medically necessary. The Plan 
denied your request. The Plan says it 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 intraoperative neuromonitoring.  
 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this type of testing has not been shown to be of utility or benefit in 
single level lumbar procedures either. Multiple research studies have failed to demonstrate that the 
intraoperative neurophysiological monitoring (IONM) monitoring is of clinical utility or benefit. It has not been shown to benefit the overall health outcome or reduce intraoperative injury. In as much this service would not 
meet the definition of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraoperative neuromonitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for intraoperative neuromonitoring provided on May 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of iron dextran, dexamethasone sodium phosphate, 
famotidine, and hydrocortisone. 
 
You asked the Plan to pre-approve iron dextran regimen. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is no evidence of iron deficiency anemia. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 iron dextran regimen. Our reviewer 
says that the enrollee does not meet criteria for this drug combination. Our physician reviewer found the 
enrollee has no documentation of iron deficiency anemia. There is no ferritin and both the hemoglobin and 
mean corpuscular volume (MCV) are normal. This infusion is neither medically reasonable nor 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 iron dextran regimen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of iron dextran, dexamethasone sodium phosphate, famotidine, and 
hydrocortisone.
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 these services are medically necessary for the 
enrollee. 
 The Plan denied your request. The Plan says these services are 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee already has this same kind of bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found that the enrollee enrollee 
requires head of bed to be elevated for tube feeding but had an existing semi-electric bed since 2021. 
Replacement of durable medical equipment in less than 5 years of use is not 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 the bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories 
(E0955, E1002, E1028, E2310, E2361, E2603). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee is unable to 
propel an optimally configured manual wheelchair due to his safety and functional decline that prohibits him to 
propel the manual wheelchair from his decrease limitations fatigue onset due to the physical exertion. He 
cannot operate a tiller system due to his limitations and pain in his shoulders. A standard power wheelchair 
does not meet medical necessity for him due to his diagnosis. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for a single power option included with a group 3 power wheelchair. 
 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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has COPD and osteoarthritis. He is able to stand. Per 
L33789, the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity 
or require an alternative means of managing a power drive. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories (E0955, 
E1002, E1028, E2310, E2361, E2603).
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the notes do not show that the enrollee's care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-care 
functioning.  
 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 can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower 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.