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

 
We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoe, depth inlay, each 
(CPT Code L3216). 
 
You asked the Plan to pre-approve foot orthotics. You say that the patient has already been provided with a 
ASO braces; however, they do not provide the patient with complete relief and you believe that they would 
benefit from bilateral custom orthotics, which will include medial hind foot posting and longitudinal arch 
support. You state it is medically necessary and appropriate for this to be included in the patient's treatment 
plan. The Plan denied your request. The Plan says this patient does not have a qualifying condition for shoe 
inserts. The Plan states that this patient is not diabetic and the shoe/orthotic is not an integral part of a brace or 
prosthetic. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic footwear, ladies shoe, depth inlay, each (CPT Code L3216).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) rental. 
 
You asked the Plan to pre-approve a CPAP rental. You say that the requested item is necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
has not been met. 
 
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 a CPAP rental. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the requested CPAP rental in this case are medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CPAP rental have been met. Therefore, we decided that the Plan has to pre-
approve a continuous positive airway pressure (CPAP) rental.  
 
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: 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 the enrollee requires LTACH care as any 
other level of care would be unable to meet her needs. The Plan denied your request. The Plan says the 
enrollee's condition does not require care in the LTACH setting. 
 
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include hemodialysis, surveillance laboratory studies, ongoing 
nutritional assessments, and therapy services. The documentation does not support that the enrollee in this case 
requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS HF System (CPT Code 33289) and (CPT 
Code C2624). 
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the device is considered to be experimental or 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CardioMEMS HF System (CPT Code 33289) and (CPT Code C2624).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve ambulance service, basic life support, non-emergency transport, 
(bls) (CPT Code A0428). 
 
You asked the Plan to pre-approve ambulance services. You say that the service is needed because the enrollee 
was presented with walking difficulties and weakness. The Plan denied your request. The Plan says that the 
medical documentation received does not support this service because there is no medical need for the enrollee 
to require an ambulance. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same 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 ambulance services. Our physician 
reviewer found this is a patient with central nervous system (CNS) pathology. The patient has a seizure 
disorder and is elderly. There was reason to rule out cerebrovascular accident (CVA). Given fall risk and 
instability risk, the ambulance transport was medically reasonable and appropriate. The documentation 
supports the need for the support devices with ambulance transport. It supports ambulance transport as the 
appropriate level of transportation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has to 
pre-approve ambulance service, basic life support, non-emergency transport, (bls) (CPT Code A0428).  
 
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 repair of blepharoptosis; (tarso) levator resection or 
advancement, internal approach (CPT Code 67903). 
 
You asked the Plan to pre-approve the service. You say that you need the surgery because you have bad vision 
in both eyes and are not able to see very well. The Plan denied your request. The Plan says your records fail to 
document the necessary visual field testing and photographs supporting medical necessity for the procedures. 
 
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 there is no documentation of at least 12 degree or 30% loss of upper field of vision loss which is required 
and supported by photographs which are not provided. 
 
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 repair of blepharoptosis; (tarso) levator resection or advancement, internal approach (CPT 
Code 67903).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires lysis of adhesions in 
order to recover and avoid being placed on hospice. A SNF stay should be allowed to try to allow her to 
increase her level of function so that she can be cleared for surgery. The Plan denied your request. The Plan 
says the enrollee does not requires daily skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is suffering from altered 
mental status and SNF services are requested to help build strength and endurance for a surgery for the lysis of 
adhesions.  
 
The records do not document any skilled nursing needs. There is evidence of a need for skilled therapy but the 
documentation does not support that skilled services are medically reasonable and necessary for this enrollee 
on a daily basis in a skilled nursing facility setting on an inpatient basis. 
 
 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 you need rehab to regain normal function and walk 
on your own. The Plan denied your request. The Plan says you do not need physician assessment 3 or more 
times a week, or need specialized therapeutic skills or equipment. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you are at a moderate assist level for transfers, and minimum to maximum assist for activities of daily 
living. There is no report of any medically unstable conditions. The complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services, but you do not require 
an intensive inpatient rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this would be best used concurrently with Carboplatin and Paclitaxel. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found 
Carboplatin/Taxol/Keyruda is not compendia-based for ovary cancer. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can be safely treated at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, anterior interbody technique, including 
minimal discectomy to prepare interspace (other than for decompression); lumbar (CPT Code 22558), removal 
of anterior instrumentation (CPT Code 22855), insertion of interbody biomechanical device(s) (eg, synthetic 
cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, 
to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (CPT Code 22853) and 
allograft, morselized, or placement of osteopromotive material, for spine surgery only (CPT Code 20930). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested hospital stay isn't covered because it's associated with a 
procedure that isn't covered. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria of lumbar fusion have not been met. The diagnosis of failure of previous fusion has 
not been established. The computed tomography (CT) scan does not clearly show failure of fusion. The 
imaging studies do not show clear failure of fusion. There is no instability. 
 
 
 
 
 
 
 
 
 
 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, anterior interbody technique, including minimal discectomy to prepare 
interspace (other than for decompression); lumbar (CPT Code 22558), removal of anterior instrumentation 
(CPT Code 22855), insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral 
anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc 
space in conjunction with interbody arthrodesis, each interspace (CPT Code 22853) and allograft, morselized, 
or placement of osteopromotive material, for spine surgery only (CPT Code 20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMs heart failure monitor. 
 
You asked the Plan to pre-approve the CardioMEMs monitor. You say that this treatment is necessary to assist 
in managing poorly controlled heart failure. The Plan denied your request. The Plan says this is an 
investigational service and cannot be covered. 
 
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 CardioMEMs monitor. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found in this circumstance, therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met, in my opinion, since the device should still be considered experimental or 
investigational. 
 
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 CardioMEMs monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMs heart failure monitor.
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 the care and services required exceeds 
the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care, and does not require transfers. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with COVID-19, requiring 
BiPAP, steroids, Remdesivir, and convalescent plasma. She has since been able to wean to 6L NC oxygen 
supplementation, but requires ongoing PT, oxygen weaning, and monitoring. The enrollee appears to be 
improving, and should not require more than 24 days of inpatient acute care services. There are no services in 
the LTACH that are not already available and covered in the current setting. Therefore, the LTACH services 
will be considered not medically necessary 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ENTYVIO for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has implemented step therapy rules for this drug. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
tried and failed the required drugs. Based on the medical records provided there is no indication that the plan's 
required drugs would likely be less effective and/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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ENTYVIO for the enrollee.