Persius/hicric huggingface dataset:
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer may be considered with more time at the current facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a CardioMEMS heart failure monitor. 
 
You asked the Plan to pre-approve the CardioMEMS system. You say that this is medically necessary and will 
improve the enrollee's quality of life. The Plan denied your request. The Plan says the requested device is an 
FDA Category B Investigational Device Exemption item. The Plan says that the enrollee is not in a Medicare-
approved 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 the CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a CardioMEMS heart failure monitor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay an additional payment for PPE and decontamination of the 
ambulance during and after ambulance services were provided, on April 10, 2020. 
 
You asked the Plan to pay for additional payment for PPE and decontamination of the ambulance. The Plan 
denied your request. The Plan says additional reimbursement for PPE and decontamination of your vehicles 
remains denied since Medicare attests payment in full for all services, supplies, and other costs once the 
transport claim has been paid according to the Medicare ambulance fee schedule 
 
The Plan must follow Medicare rules. Medicare rules say that payment for ambulance services is based on the 
lesser of the actual charge or the applicable fee schedule amount.  

We looked at the file and Medicare rules. Medicare says payment for ambulance services is based on the lesser 
of the actual charge or the applicable fee schedule amount. Therefore, we decided that the Plan does not have to 
pay an additional payment for PPE and decontamination of the ambulance during and after ambulance services 
were provided, on April 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan (93880) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a duplex scan to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a duplex scan (93880) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has symptomatic anemia 
felt to be multifactorial related to low risk myelodysplastic syndrome, as well as stage IV chronic kidney 
disease. He has not tried and failed the Plan's required drug of Retacrit. The records do not support that the 
required drug would be contraindicated or less effective; therefore, Aranesp is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the pelvis 
(72191). 
 
You asked the Plan to pre-approve a CTA of the pelvis. You say that the services are 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 CTA of the pelvis. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found based upon the enrollee's underlying disease, prior carotid dissection and new onset of 
claudication the request for CTA of the lower extremities is 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 CTA of the pelvis have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomographic angiography (CTA) of the pelvis (72191).  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64636, 64635). 
 
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. 
The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the coverage criteria non-thermal modalities for facet joint denervation including 
chemical, low-grade thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are not 
considered medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) (64636, 64635).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our 
physician reviewer found based on the medical records provided 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. There is concern that you will not be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate in this case. 

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 a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 CardioMEMS device. 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 6, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case.  
 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery for the billed date of service. Therefore the billed code cannot be verified.  The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the 
enrollee on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a joint stabilizer (L2385) provided to the enrollee on April 9, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case.  
 
 
 
 
 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery for the billed date of service. Therefore the billed code cannot be verified. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, 
L2397) with a joint stabilizer (L2385) provided to the enrollee on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) with 
a joint stabilizer (L2385) provided to the enrollee on April 8, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case.  
 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies, or proof of delivery for the billed date of service. Therefore the billed code cannot be verified.  The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, 
L2397) with a joint stabilizer (L2385) provided to the enrollee on April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on 
June 17, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment within six months of the date of service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth.  
 
 
 
 
 
 
 
 
 
The submitted consultation notes do not support that a physical examination was performed regarding the 
billed code. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the 
enrollee on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are diabetic and need the orthotics to 
help/support your walking. The Plan denied your request. The Plan says this item is not a covered benefit. 

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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow or Fluid GF (Q4206 X2). 
 
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 services are 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Fluid Flow remains experimental for spinal conditions. More research is needed to show the 
safety and efficacy of Fluid Flow for the treatment of intra and extra spinal pathology. 
 
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 Fluid Flow or Fluid GF (Q4206 X2).