Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open aortic replacement with aortic hemiarch graft for 
the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee has a rapidly forming aortic 
aneurysm. The Plan denied your request. The Plan says the records do not show aortic aneurysm measuring 5.5 
cm or larger, or 4.5 cm or larger in presence of bicuspid aortic valve. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the echocardiogram shows mild-moderate aortic regurgitation with tricuspid valve, and an 
increasing aortic dimension, measured at 4.7 cm. The guidelines would not support this request based on the 
submitted records. It would not be necessary in the 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve open aortic replacement with aortic hemiarch graft for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom prosthetic partial hand and finger prosthesis. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not reasonable and necessary, and exceeds the enrollee's need. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is a lack of high quality evidence in the literature of functional outcomes for partial hand 
prosthesis with the requested body powered naked prosthetics. Additionally, a review of the specifications 
reveals that the items exceed the patient's functional needs. Per the Naked Prosthetics Product Technical 
Specifications the prosthetics are designed to get workers back to difficult jobs, and for people who use their 
hands in harsh environments. All products are resistant to most common chemicals such as isopropanol, 
ethanol, acetone, and oil, as well as water, dust and dirt. The prosthetics come in multiple color options as well. 
These features exceed the patient's medical and functional need and do not meet the criteria for 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 the item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom prosthetic partial hand and finger prosthesis.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a power mobility device (power scooter). 
 
You asked the Plan to pre-approve power mobility device. You say that you have trouble using your manual 
wheelchair due to bad shoulders. The Plan denied your request. The Plan says that the denial of authorization 
for this device is correct, because you do not meet coverage criteria for a power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 power mobility device. Our reviewer 
says that you meet the Medicare criteria for the requested power mobility device. Our physician reviewer found 
documentation from the provider states that you have difficulty completing activities of daily living (ADLs) 
resulting in multiple complications and your current manual wheelchair no longer meets your needs which 
would not be ameliorated by a walker, cane, or manual wheelchair due to your condition. The documentation 
states that you are already safely operating a borrowed power mobility device within the home and are using it 
for ADLs and mobility within your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power mobility device have been met. Therefore, we decided that the Plan has 
to pre-approve a power mobility device (power scooter).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting. The Plan denied your request. The Plan says an intensive rehabilitation 
program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab 25MG/ML; Administer 200MG into 
vein every twenty-one days. 
 
You asked the Plan to pre-approve the medication. You say that the addition of the pembrolizumab would 
benefit this enrollee. The Plan denied your request. The Plan says the requested agent is not FDA approved, nor 
compendia listed nor endorsed by National Comprehensive Cancer Network (NCCN) for this members 
condition. The Plan states there was no submission by the requesting Provider of any primary literature to 
support the use of the requested medication in this setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of pembrolizumab 25mg/ml; Administer 200mg into vein every twenty-one days is not 
FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab 25MG/ML; Administer 200MG into vein every twenty-one days.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma injections provided March 30, 2022. 
 
You asked the Plan to pay for the platelet rich plasma injections. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that platelet rich plasma injections and/or 
applications are considered not medically reasonable and necessary for any use outside of the National 
Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic Non-Healing Wounds. 
 
We looked at the file and Medicare rules. This use was not for non-healing wounds. Based on this information, 
we decided that Medicare rules for coverage of the platelet rich plasma injections have not been met. 
Therefore, we decided that the Plan does not have to pay for platelet rich plasma injections provided March 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lateral sacral branch joint nerve destruction. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary due to long-term 
endurance of sciatica pain in the spine The Plan denied your request. The Plan says the records do not show 
two diagnostic medial branch blocks yielding 80% or better improvement in pain. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental because of the wide variation in efficacy reported in the 
literature. Therefore, the request is deemed not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lateral sacral branch joint nerve destruction.
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 enrollee is having weakness and would improve 
from rehabilitation care. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information received, the enrollee does not meet the requirements and can receive care in another 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hillrom Valera System. 
 
You asked the Plan to pre-approve the Hillrom Valera System. You say that you used this while in the hospital 
and it worked great for you after having tried everything. The Plan denied your request. The Plan says there is 
not enough detailed information provided to justify this treatment over other available respiratory assist devices 
(RADs). 
 
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 Hillrom Valera System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no evidence that combining these three modalities is beneficial in 
the outpatient treatment of lung disease. The airway oscillation has not been compared to other clearance 
techniques for airway clearance. The denial is upheld. 
 
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 Hillrom Valera System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Hillrom Valera System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on September 14, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you will not pay for hearing aids that you returned. 
The Plan denied your request. The Plan says you will not be reimbursed for hearing aids that are not the Plan's 
approved hearing aid brand and purchased OON. 
 Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid brand, and they are rendered by an in-network 
provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) provided on September 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oxygen concentrator (CPT code E1390RR). 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that the oxygen concentrator is necessary. 
The Plan denied your request. The Plan says the enrollee is using inhalers and is doing well. The Plan states 
there is no mention of dyspnea, no report of any oxygen levels having been checked at any time, no history of 
oxygen (O2) use reported, no mention that oxygen is needed or is being requested. The Plan states the main 
issue appears to be pain management of musculoskeletal problem. 
 
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 oxygen concentrator. Our physician 
reviewer found home supplemental oxygen is not medically necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD). An office visit January 7, 2022, showed SpO2 of 98%. The progress 
notes do not mention a need for oxygen, and there is no documentation of hypoxemia. The denial is upheld. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the oxygen concentrator (CPT code E1390RR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for remote monitoring treatment management 
provided on January 31, 2022. 
 
You asked the Plan to waive the deductible for remote monitoring treatment management. You say that you 
never saw this provider. The Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $750 deductible which applies to Physician/Practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
remote monitoring treatment management was received on January 31, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for remote monitoring treatment management provided on January 
31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
He had prior RFA of the medial branches but there is no documentation of the degree and duration of pain 
relief. The criteria for coverage are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network benefit coverage with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that you are requesting in-network benefit coverage 
with an out-of-network provider. The Plan denied your request. The Plan says they have in-network providers 
that can provide the services. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. This service is available by a 
provider in your network; however, if you choose to receive services from this out-of-network provider, your 
share of the cost for your covered services may be higher. Therefore, we decided that the Plan does not have to 
pre-approve in-network benefit coverage with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have 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 that the review indicates that the enrollee is a 72-year-old female with a significant 
past medical history of chronic obstructive pulmonary disease, emphysema, lung cancer, and on home oxygen 
(2-3 liters per minute) who was hospitalized on June 8, 2022, with acute on chronic hypoxic respiratory failure, 
COVID-19 infection, and syncopal episodes placed on high flow oxygen. In this case, there is no 
documentation provided indicating medical necessity for admission to an LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only 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 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.