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

 
We decided that the Plan has to pre-approve a stance flexion feature (L5845), fluid stance extension, 
dampening feature (L5848), polycentric, hydraulic swing phase control, mechanical stance phase lock (L5814), 
and all lower extremity prostheses, flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a stance flexion feature, dampening feature, polycentric, hydraulic swing 
phase control, mechanical stance phase lock, and flex-walk system or equal. You say that you would like this 
request to be reprocessed for approval. The Plan denied your request. The Plan says that this request for K3 
knee and foot does not meet Medicare criteria as reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
 
 
 
 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 stance flexion feature, dampening 
feature, polycentric, hydraulic swing phase control, mechanical stance phase lock, and flex-walk system or 
equal. Our reviewer says that this request is medically reasonable and necessary for the enrollee. Our physician 
reviewer found the preponderance of evidence is the enrollee is a K3 ambulator. Our reviewer also found that it 
is the Plan's responsibility to obtain and submit physician records. 
 
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 stance flexion feature, dampening feature, polycentric, hydraulic swing phase 
control, mechanical stance phase lock, and flex-walk system or equal have been met. Therefore, we decided 
that the Plan has to pre-approve a stance flexion feature (L5845), fluid stance extension, dampening feature 
(L5848), polycentric, hydraulic swing phase control, mechanical stance phase lock (L5814), and all lower 
extremity prostheses, flex-walk system or equal (L5981).  
 
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: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that based on the additional information available, the request does not meet the 
Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that emerging data, including a 2021 systematic review and meta-analysis show that SBRT along with 
systemic therapy, for early stage, node negative small cell lung cancer (SCLC) results in comparable outcomes 
to concurrent chemoradiation. Given that these guidelines establish standard of care treatment, and that the 
patient is described as having inoperable disease, and is a candidate for chemotherapy after radiation, this 
treatment would be furnished in accordance with accepted standards 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 the therapy have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 21315 and 99285 provided to the enrollee 
on June 13, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 21315: 
 
Closed treatment of nasal bone fracture with manipulation; without stabilization 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided 
does not include sufficient documentation to validate that CPT 21315 was rendered in this case. This procedure 
cannot be verified. Additionally, the records do not support the level of care described by CPT 99285. This 
service cannot be verified. 
 
We looked at this coder'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 pay for procedure codes 21315 and 99285 provided to the enrollee on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 fractions of intensity modulated radiation therapy 
(IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no planning records provided demonstrating that a 3D conformal plan would be 
unacceptable, which is generally needed to demonstrate the need for IMRT for non-standard approachesThe 
letter of appeal describes the need for IMRT to allow sparing of the skin over the port.  That may indeed be a 
justification for IMRT, but in the absence of planning records showing this, and also in the absence of a 
plausible rationale for such a high dose for palliation, the records do not demonstrate need. Additionally, the patient is to receive a new systemic agent (Parjeta) which may afford control. This is not medically necessary 
due to the case records not demonstrating need and the treatment not being in accordance with accepted 
standards (and the case file not providing any evidence to support such a treatment). 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 20 fractions of intensity modulated radiation therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hair removal. 
 
You asked the Plan to pre-approve hair removal. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hair removal have been met. 
Specifically, medical records were requested but not received. Medical necessity cannot be established without 
this documentation. Therefore, we decided that the Plan does not have to pre-approve hair removal.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence showing that this requested device would improve the 
outcomes for this problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure in this patient. 
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 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you cannot walk, need wound care 
assistance and are in constant pain. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care setting. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that based on the enrollee's current medical 
condition, the requested LTACH care is necessary. The Plan denied your request. The Plan says the enrollee 
does not require an LTACH admission and care. 
 
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 here is no documentation provided indicating the medical necessity for 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84520 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for procedure code 84520. You say that this service was reported correctly and is 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 84520 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 84520 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 84520 billed for date of service September 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate. 
 
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. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
thrombocytopenia in the setting of high risk myelodysplastic syndrome. The Food and Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. 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 Nplate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body, prefabricated 
abutment and an abutment supported crown for tooth numbers 3 and 14. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary for patient to 
chew and masticate food properly. The Plan denied your request. The Plan says that clinical guidelines have 
not been met. For these services to be approved, you must have at least 8 permanent back teeth that bite 
together. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that that the criteria for coverage has not been met. Our physician reviewer found that the documentation 
reveals severe periodontal disease. Placement of implants at this time are not in accordance with reasonable 
dental practices. The enrollees periodontal disease must be treated and stabilized, and hopeless teeth removed 
prior to formulating a treatment plan which may include implants. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the surgical placement of implant body, prefabricated abutment and an abutment 
supported crown for tooth numbers 3 and 14.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab. 
 
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 not tried and failed the 
Plan's required drug, an injectable bisphosphonate. The records do not show that the required drug would be 
contraindicated or less effective; therefore, Denosumab 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 Denosumab.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan. 
 
You asked the Plan to pre-approve a computed tomography angiography (CTA) scan. You say that you would 
like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 computed tomography angiography 
(CTA) scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found there 
is no documented reason a repeat is 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 computed tomography angiography (CTA) scan have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
October 4, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the physician provided 
medically necessary services in good faith. The Plan denied your request. The Plan says there is inadequate 
documentation provided to support the medical necessity for repeat professional visits at a frequency which 
exceeds Medicare guidelines. 
 The Plan follows Medicare rules. Medicare rules say that frequent visits by the physician in a nursing home 
setting would then be unnecessary, particularly if the patient is medically stable. 
 
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 evaluation and management service. Our 
reviewer says that the evaluation and management service was not medically necessary. Our physician 
reviewer found the provided documentation does not explain why the enrollee needed to be seen on the date of 
service in this case. The reviewer found that the documentation does not indicate there was evidence of a new 
complaint, injury, or illness. Therefore, the reviewer found that the evaluation and management service was 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 evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on October 
4, 2022.