Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a noninvasive ventilator (E0466) and an oxygen 
concentrator (E1390). 
 
You asked the Plan to pre-approve a noninvasive ventilator and an oxygen concentrator. You say that the 
requested devices are medically necessary for the enrollee. The facility she is in does not provide a ventilator 
for enrollees, only bipap with backup rates at the most. Per physician notes, this has shown to fail in lowering 
members C02 retention. The Plan denied your request. The Plan says Medicare indicates a SNF is an institution 
and is not considered an enrollee's home. An enrollee in a SNF is not entitled to have separate Part B payment 
made for the rental or purchase of DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a noninvasive ventilator and an oxygen concentrator is being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a noninvasive ventilator (E0466) 
and an oxygen concentrator (E1390).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine extractions, resin composites and full mouth 
debridement. 
 
You asked the Plan to pre-approve the dental services. You say that you would like reconsideration because the 
enrollee's considerable tooth decay makes them vulnerable to infections. The Plan denied your request. The 
Plan says the denied services are not covered by the enrollee's 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
routine extractions, resin composites and full mouth debridement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our reviewer found that according to the applicable NCD, a PET scan of 
the brain is covered for use in individuals who meet diagnostic criteria for both AD and FTD. However, the 
records did not indicate that the enrollee met the diagnostic criteria requirements for both AD and FTD. 
Additionally, the enrollee is suspected of having vascular dementia. Given that the diagnostic criteria for both 
FTD and AD are not met, and other causes of dementia have not been ruled out a PET scan cannot be 
recommended at this time.  
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the magnetic resonance imaging (MRI) provided shows foraminal stenosis. The cause of the 
enrollees 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (64628, 64629).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on October 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these tests were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that these services should only be 
billed as a single code and unit of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not cited the rule used to make their decision and we 
were unable to find this information in a determination which applies to the state where these services were 
provided. In addition, the services at issue were each reported with the -59 modifier, indicating that they were 
provided as separate and distinct services. It does not appear that the Plan has performed a review to determine 
whether the reported modifiers were appropriate or not. The Plan has not fully substantiated their denial in this 
case. Therefore, we decided that the Plan has to pay for laboratory services provided on October 19, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the myocardial perfusion imaging, tomographic 
(SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first 
pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress 
(exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in need of the procedure in order to 
return to maximum function. The Plan denied your request. The Plan says your request is not medically 
necessary because the enrollee's records do not show that the enrollee has any of the covered indications for 
stress testing with cardiac imaging. 
 
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 service. Our physician reviewer 
found at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. The 
enrollee has no symptoms, with a negative stress test in 2020 and echocardiogram in 2022 showed normal 
ventricular function. There is no evidence provided that would support the need for radionuclide stress testing 
at this time. In summary, there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in this enrollee's clinical 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the myocardial perfusion imaging, tomographic (SPECT) (including attenuation 
correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 
quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or 
redistribution and/or rest reinjection (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L2 kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 the service. Our physician reviewer 
found detailed documentation is not evident regarding worsening pain. There is no indication there is 
progression of vertebral body height loss, greater than 25 percent vertebral body height reduction, severe 
impact of vertebral compression fracture, or steroid-induced fractures. Moreover, the provided diagnostic 
imaging studies corroborate plausible other causes of pain in the lumbar spine. This is a noted contraindication 
for kyphoplasty. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the medical records provided 
do not meet the requirements listed in the LCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the L2 kyphoplasty (22514).
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. The Plan denied your request. The Plan says the IRF services 
requested is not supported based on the records received. Services needed may be provided safely in a skilled 
nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are requesting prior authorization 
for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. The 
Plan denied your request. The Plan says there is not enough medical proof that shows the safety and or success 
of this procedure. 
 
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 procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows foraminal stenosis and the cause of 
back 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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve InnovaMatrix AC skin substitute. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the wound is improving with current wound care, with a reduction in size, area, and 
dimensions from April 17, 2023, to April 25, 2023. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation supports that this enrollee is suffering with a right lower leg/ankle 
venous ulceration. The enrollee has been receiving adequate wound care, offloading, and other medications 
such as Santyl and Amerigel. Unfortunately, the enrollee's wound is not healing. The most recent progress 
notes from April 2023 reveal an increase in size of the ulceration from 3.4 cm x 3.3 cm x 0.5 cm to 3.9 cm x 
3.6 cm x 0.5 cm. Skin substitutes have been Food and Drug Administration (FDA) approved for the treatment 
of diabetic foot ulcerations and venous ulcerations. They have been shown to be effective in facilitating healing 
of chronic wounds. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve InnovaMatrix AC skin substitute.  
 
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 pay for the services provided on December 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on January 13, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on December 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you need additional physical therapy. 
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 that you 
appear to have improved with therapy to the point of being able to ambulate household distances with a rolling 
walker with stand-by assistance and are stand-by assist for transfers. Records indicate that you have been 
instructed on a home exercise program. After the seven physical therapy treatments already provided, records 
do not support that the complexity of your conditions are such that the skills of a professional therapist are 
required to achieve further improvement in your symptoms or functional status. No medical notes from your 
treating physician are provided documenting an order or need for additional skilled physical therapy services. 
Further utilization of the home exercise program appears appropriate at this point. 
 
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 9 additional home health physical therapy visits.
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 authorization. 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 enrollee 
may require some degree of supervision for safety, but they do not require the services of a skilled physical 
therapist. The enrollee can continue with a home exercise program for continued improvement of endurance. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747). 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that the enrollee needs the requested 
device. The Plan denied your request. The Plan says the request 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 an osteogenesis stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided records in this case do not document a nonunion of a long bone 
fracture defined as radiographic evidence that fracture healing has ceased for three or more months prior to 
starting treatment with the osteogenesis stimulator, or failed fusion of a joint other than in the spine where a 
minimum of nine months has elapsed since the last surgery, or a congenital pseudarthrosis. As stated in the 
Local Coverage Determination (LCD) Osteogenesis Stimulators L33796: "Nonunion of a long bone fracture 
must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the 
osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, 
and with a written interpretation by a treating practitioner stating that there has been no clinically significant 
evidence of fracture healing between the two sets of radiographs." Provided records in this case document the 
non-union is related to the prior osteotomy and not a fracture. 
 
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 osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (E0747).
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 authorization. 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 enrollee 
may continue to require assistance with daily activities and supervision for safety, but they do not require the 
services of skilled physical therapist or skilled nursing 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.