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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a BiPAP does not provide the level of ventilatory 
support to meet the enrollee's needs. The Plan denied your request. The Plan says settings that could be 
delivered by BiPAP are not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that a Life2000 system was requested. This is not a true ventilator because it is not capable of providing 
full ventilatory support. It is designed to provide positive pressure oxygen during activity. There is inadequate 
evidence that this device is effective in the treatment of any lung disease.  In addition, the enrollee does not meet criteria for a respiratory support device during sleep because there is no 
evidence of carbon dioxide retention.  It is not clear from the records whether the enrollees sleep apnea is 
being treated. Therefore, the requested device is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are requesting approval for the 
admission to a new skilled nursing facility as of 3/23/2022. The Plan denied your request. The Plan says the 
services and care that you need can be provided at the original facility. There was no emergency situation that 
required transfer to another facility and the new facility did not request approval before admitting you. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found Based on the documentation 
provided, it is my opinion that the health plans denial should be upheld. There is no evidence that the required 
services are not currently available.  As such, the requested SNF-to-SNF transfer is not medically necessary or 
reasonable. 
 
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 the skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the services are necessary. The 
Plan denied your request. The Plan says the CardioMEMS device at this point should only be approved for 
patients enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a 
clinical trial of the device. 
 
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 the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of patients with congestive heart failure (CHF).  The clinical study on which Food and Drug Administration (FDA) approval was based showed improved 
clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope (1). 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device (2). In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees 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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and C2624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One injection. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the enrollee has previously received a right knee 
Synvisc injection in December 2021 which had been beneficial. The Plan denied your request. The Plan says 
the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat series of injections may be allowed when the 
last injection (in a prior course) was given at least six (6) months ago. 
 
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 Synvisc-One. Our reviewer says that 
the requested injection is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has previously received the requested service in December 2021. The reviewer found that 6 months 
has not lapsed since that time and by rule, the requested service is not available for overage 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One injection.
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 patient is stable and medically ready 
to admit to LTACH for continued care. You also say that multiple issues are complicating overall medical 
management, and the patient will require 6 plus hours of skilled nursing care and daily physician evaluations. 
You also say that therapies provided for strengthening, debility, and endurance as appropriate, and multiple 
medical modalities required in patient care and are available at this facility. The Plan denied your request. The 
Plan says that your records do not show that you will probably require an average 25 day length of stay in the 
LTACH, and your continued care needs include, weaning trials and therapy. The Plan also says that when you 
are ready to leave the hospital, you can safely receive this care in another setting, such as a Skilled Nursing 
Facility (SNF) or at home with home health services out outpatient 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 the patient appears to be improving and should only require short-term additional 
acute care services that can be safely completed at the current facility until appropriate for a lower level of care, 
and the patient does not require services at the LTACH that are not already available at the current facility. Our 
doctor also found that there are no services at the LTACH that the patient requires that are not already available 
and covered at the current facility. Our doctor also found that transfer to LTACH is not medically necessary as 
it would not be clinically advantageous, and transfer may be considered when treatment has completed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and testing services provided on January 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained for these services rendered by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and testing services provided on 
January 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete blood count and vitamin B-12 injection (96372, 
85025 and J3420) provided on October 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete blood count and vitamin B-12 injection. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no 
evidence that these services were urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the complete blood count and vitamin B-12 
injection (96372, 85025 and J3420) provided on October 8, 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 home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator with settings that could be 
delivered by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
for this member with chronic obstructive pulmonary disease (COPD) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the settings requested will provide an assistance of approximately 
3 l/s, which can be achieved with BiPAP-AVAPS. The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device is 
covered. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a cardiac rhythm monitor. 
 You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical necessity is not established based on the NCD and an assessment of the medical 
literature. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram (ECG) monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an implantable loop recorder (ILR) (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients 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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a cardiac rhythm monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
obstructive sleep apnea syndrome (OSAS). The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in intelligent volume-assured pressure support (iVAPS-AE) mode that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the record indicates that you have chronic respiratory failure in the setting obstructive sleep 
apnea, previous COVID-19 and asthma. These are not conditions that are enumerated as covered under the 
rules. Furthermore, the record does not indicate that BiPAP with AVAPS setting would not be appropriate for 
you or that you have failed such therapy.  The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. 
The plan has indicated such a device is available for coverage consideration. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis injection (J7322) and administration (20610). 
 
You asked the Plan to pre-approve the injection. You say that the pain you have is extreme and constant. You 
say that this is your last hope before going to surgery.  You also say that you cannot afford to pay for this medication out of pocket. The Plan denied your request. The 
Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
ALL of the following conditions 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 the injection. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found the record indicates that you have 
knee pain. The reviewer found that the diagnosis of osteoarthritis is not supported by the imaging studies 
provided. The record provided does not document the failure of nonpharmacologic therapy or simple analgesics 
in at least a three month trial of therapy or that there is a contraindication to such a trial. The reviewer found 
that the elements of the coverage criteria are not satisfied. Therefore, the reviewer found that the requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hymovis injection (J7322) and administration (20610).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee is still experiencing pain. The 
Plan denied your request. The Plan says additional physical therapy sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy sessions to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin, Vitamin D, lead and mercury testing 
(83655, 83825, 83036 and 82306) provided on October 27, 2021. 
 
You asked the Plan to pay for the hemoglobin, Vitamin D, lead and mercury testing. You say that you would 
like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says 
the enrollee does not have a condition which would indicate coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the hemoglobin, Vitamin D, lead and 
mercury testing. Our reviewer says that the records do not indicate that the enrollee is being prescribed vitamin 
D supplementation or that they had a prior low vitamin D. There was no documentation or record of liver 
abnormalities, parathyroid problems, osteoporosis, diabetes, heart disease, kidney disease, abnormal cholesterol 
issues, history suggesting risk to lead or mercury exposure, or prior abnormal testing for either Vitamin D, Hgb 
A1C, lead, or mercury to justify the above tests at this time. Our physician reviewer found without sufficient 
support made, theses tests will be considered not medically necessary based on the provided documentation. 
 
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 hemoglobin, Vitamin D, lead and mercury testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the hemoglobin, Vitamin D, lead and mercury 
testing (83655, 83825, 83036 and 82306) provided on October 27, 2021.