Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MolDX. 
 
You asked the Plan to pre-approve MolDX. 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 follows Medicare rules. Medicare rules say that MolDX will review all new test/assay clinical 
information to determine if a test meets Medicares reasonable and necessary requirement. 
 
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 MolDX. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review indicates that the enrollee has 
stage IV lung cancer metastatic to the brain. The provider had planned to test with a Tempus genetic test, but 
instead has ordered the above test, to be run at the Henry Ford lab. Search of the Food & Drug Administration 
(FDA) companion in vitro diagnostic testing site does not list this test from the Henry Ford lab as an approved 
companion diagnostic test. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MolDX have not been met. Therefore, we decided that the Plan does not have to 
pre-approve MolDX.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to repair broken teeth. 
 
You asked the Plan to pre-approve dental services to repair broken teeth. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says dental services beyond Medicare 
coverage are not covered by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental services to 
repair broken teeth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro 2 Motion G Myoelectric arm orthosis. 
 
You asked the Plan to pre-approve MyoPro 2 Motion G Myoelectric arm orthosis. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is 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 MyoPro 2 Motion G Myoelectric arm 
orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro 2 Motion G Myoelectric arm orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve MyoPro 2 Motion G Myoelectric arm orthosis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan 
says the requested 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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of 
chronic low back with radiation to the right leg. Interlaminar spacer devices remain experimental. More 
research is needed. Therefore, the enrollee does not meet criteria for the requested services. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 10 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue 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 an additional 10 PT visits. 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 records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. You should be able to transition to an independent home program at this point. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 10 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 10 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee does not have a mobility deficit that impairs your participation in MRADLs or 
the enrollee's condition can be improved by a walker, cane or manual wheelchair. This means that Medicare 
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied IRF services with 
medical records. The Plan denied your request. The Plan says there was no previous hospital stay or evaluation 
showing that the enrollee needed inpatient level of nursing and therapy care. The therapy being given does not 
show the need for a special team approach with therapy, nursing and physicians. The enrollee's current care 
could be given at a lower level of care. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of stroke and is having frequent episodes of falling. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a 
statement that you still need oxygen was not received. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements.  
 
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 requested services Our physician 
reviewer found that you have chronic obstructive pulmonary disease and obstructive sleep apnea. You have 
been on oxygen for an unknown period of time. There is no formal order, qualifying oxygenation data, or 
statement in the medical record that oxygen is necessary and that you are benefitting from it. The office visit 
from March 30, 2022, records your blood oxygen level at 96%, presumably on room air. Based on the review, 
home oxygen is considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole. 
 
You asked the Plan to pre-approve Pantoprazole. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole.  
 
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee is not using insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vaginoplasty. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs to have surgery to 
stop testosterone. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 requested services. Our physician 
reviewer found that the enrollee has gender dysphoria. A progress note from July 2022 indicates that the 
enrollee has depression that is not controlled and has had previous suicidal ideation related to the decision-
making process. The record provided does not support psychological stability for the requested service. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, for 
the requested service. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vaginoplasty.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a laminectomy. We decided that the Plan does not have to pre-
approve lumbar fusion.  
 
You asked the Plan to pre-approve a laminectomy. The Plan says that the enrollee does not meet the guidelines. 
 
We decided that the Plan has to pre-approve a laminectomy.  
 
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 requested services. Our physician 
reviewer found that there is a new large disc herniation at L3-4 and other levels of stenosis. Therefore, the 
revision lumbar decompression 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 the services provided have been met. Therefore, we decided that the Plan has to 
pre-approve a laminectomy.  
 
We also decided that the Plan does not have to pre-approve lumbar fusion. 
 
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 lumbar fusion. Our physician reviewer 
found that there is no demonstrable instability on imaging. Therefore, a fusion is not medically needed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM) 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 therapeutic continuous glucose monitor (CGM)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stabilink MIS Interlaminar Spinal Fixation System 
(CPT code 22612). 
 
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your 
request. The Plan says Medicare does not cover Stabilink MIS Interlaminar Spinal Fixation System at this time. 
The Plan states interspinous process fusion devices are not proven and medically necessary when used as 
stand-alone lumbar vertebral fusion procedure. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Stabilink MIS interlaminar system is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Stabilink MIS Interlaminar Spinal Fixation System (CPT code 22612).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says this request is not medically needed due to the 
enrollee has not had a change in function that needs daily skilled therapy services. The Plan also says that the 
needs of the enrollee can be met at an alternate level of care. 
 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 SNF services. Our reviewer says that 
this does not meet criteria. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 home heath physical therapy visits. 
 
You asked the Plan to pre-approve 14 home heath physical therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 14 home heath physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 14 home heath physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 14 home heath physical therapy visits.