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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD), segmental 
home model with calibrated gradient pressure (E0652) and related accessories (E0667, E0656). 
 You asked the Plan to pre-approve the PCD and related accessories.. You say that the records provided support 
that the items in dispute will best treat the enrollee's Lymphedema. The Plan denied your request. The Plan 
says there is no documentation of a failed four-week trial using E0650 or E0651. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is only covered for the 
treatment of lymphedema extending onto the chest, trunk and/or abdomen when certain coverage criteria have 
been 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 PCD and related accessories. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a 
diagnosis of lymphedema. However, the provided records do not document lymphedema of the chest, trunk or 
abdomen or a four-week trial and failure of a standard pneumatic compression pump (E0650 or E0651). 
 
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 PCD and related accessories. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device (PCD), segmental home model with 
calibrated gradient pressure (E0652) and related accessories (E0667, E0656).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada. 
 
You asked the Plan to pre-approve Erleada. You say that you disagree with the Plan's 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 Erleada.  
 
Benefits for Erleada 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 positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the requested device does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you received a CPAP device on January 12, 2018. There is no documentation of failure of 
your current machine or inability to be repaired. The records do not show that the requested device is better 
than a generic stock brand CPAP machine. Your current CPAP device serves the same purpose as the requested 
CPAP device. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway 
pressure (CPAP) device (E0601).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucala (J2182). 
 
You asked the Plan to pre-approve Nucala. You say that you would like this to be covered for the enrollee 
under Medicare Part D until you can change over to Medicare Part B. you also say that you really want to help 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 Nucala (J2182).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphin patch. 
 
You asked the Plan to pre-approve Buprenorphin. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the requested drug is not covered under Medicare Part B. 
 
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 Buprenorphin patch.  
 Benefits for Buprenorphin 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 FreeStyle Libre continuous glucose monitor (CGM). 
 You asked the Plan to pre-approve a CGM. You say that the enrollee currently uses FreeStyle Libre. You say 
that it is what works best for the enrollee. You also say that the enrollee's blood sugars are inconsistent. The 
Plan denied your request. The Plan says a continuous glucose monitor is covered under Medicare only if the 
enrollee with diabetes is on insulin several times a day. 
 
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 a CGM have been met. Specifically, 
the file does not include any documentation to indicate that the enrollee meets any of the criteria for coverage 
for a CGM. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous 
glucose monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. 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. 
 
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 Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
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 you need physical therapy to be more self-reliant. 
The Plan denied your request. The Plan says the available records does not meet all the required criteria for 
admission to an Inpatient Rehabilitation Facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary to treat you 
and prevent infection. The Plan denied your request. The Plan says they will continue to cover medically 
necessary acute and critical care at the current facility until your condition is stable for transfer to an alternate 
level of 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) panel provided on April 
20, 2022. 
 
You asked the Plan to pay for the PCR panel. The Plan denied your request. The Plan says this testing 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 pay for the PCR panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that no PCR kits testing for onychomycosis have been FDA approved, and results appear to vary from kit 
to kit. Molecular methods appear to hold promise to achieve a rapid diagnosis. Further research, to compare 
PCR testing to current standard of care techniques, is needed to determine clinical utility and whether this technology improves health outcomes over conventional methods. The requested PCR testing is 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 PCR panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the polymerase chain reaction (PCR) panel provided on April 20, 2022.
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. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met, the enrollee's medical needs are being met in the current acute 
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 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 health 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 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 pre-approve image-guided robotic linear accelerator-based 
stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment 
(G0339) and Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including 
collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth 
sessions, maximum five sessions per course of treatment (G0340). 
 
You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT). You say that you disagree with 
the denial. The Plan denied your request. The Plan says the request does not meet the Medicare or 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 stereotactic body radiation therapy 
(SBRT). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found for this enrollee, the NCCN and ASTRO model policy 
criteria are met as he has limited metastatic disease. Arguably, all metastatic disease should be treated in one 
course. The requirement of treating the primary site first does follow from the ORIOLE and STAMPEDE 
studies, though if the intent is to treat the primary site (with standard approach of 6-20 fraction IMRT), then the 
requirement of treating the prostate first is somewhat arbitrary and for this enrollee was chosen because of 
logistics of travel. SBRT is within the accepted standards of care (as elucidated by the ASTRO model policy), 
and that it would meet the general medical necessity criteria by virtue of treatment furnished according to 
accepted standards of medical practice. However, the LCD specifies SBRT as necessary only for bone 
metastases in the vertebral bodies or paraspinous region. The criteria are therefore not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic body radiation therapy (SBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve image-guided robotic linear accelerator-based stereotactic 
radiosurgery, complete course of therapy in one session or first session of fractionated treatment (G0339) and 
Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes 
and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 
five sessions per course of treatment (G0340).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive continued medical and pain management along with physical, occupational, and respiratory 
therapies. The Plan denied your request. The Plan says the enrollee does not meet all the required Medicare 
criteria for admission to an inpatient rehabilitation facility. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says you do not meet the Medicare criteria for 
admission to an IRF. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87500, 87641, 87653) provided 
on May 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you do not have access to the enrollee's 
complete medical history or physical records. You can only provide the information you have on file, which is 
the laboratory requisition and results. You also say you would like the Plan to please review and reprocess 
claim for payment. The Plan denied your request. The Plan says the requested testing exceeds the enrollee's 
medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87500, 87641, 87653 are not supported in the medical record. Specifically, the 
enrollees medical record is missing, and documentation is required to adjudicate the claim. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for laboratory services (87481, 87500, 87641, 87653) provided 
on May 26, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for non-surgical management of a fibula fracture after a 
fall. 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 acute inpatient rehabilitation facility (IRF) admission and services.