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

 
We decided that the Plan does not have to pre-approve implantation of an Optimizer Smart pulse generator 
(0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart pulse generator. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 an Optimizer Smart pulse generator. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that cardiac contractility modulation remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 
 
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 Optimizer Smart pulse generator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantation of an Optimizer Smart pulse generator (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional chiropractic manipulative treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 requested services do not meet criteria for coverage. Our physician reviewer found that in this case, the 
record indicates that the enrollee has a lumbar subluxation. The record also indicates that the enrollee has 
chronic pain from scleroderma. The requested treatment is maintenance therapy as further clinical 
improvement cannot be reasonably expected from ongoing care. The elements of the coverage criteria are not 
satisfied. The requested services are not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 14 additional chiropractic manipulative treatments.
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 necessary to address your medical 
needs. The Plan denied your request. The Plan says you do not need monitoring by a rehabilitation doctor. 
 
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 you do not require treatment by multiple therapies.  It is unlikely that you can 
participate in and benefit from the intensity of therapies provided in an acute inpatient rehabilitation center due 
to your limited weight bearing capacity. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271) to be used in combination with Taxol 
(J9267) and Carboplatin (J9045). 
 
You asked the Plan to pre-approve Keytruda to be used in combination with Taxol and Carboplatin. The Plan 
denied your request. The Plan says this request for Keytruda does not meet the requirements for recommended 
use according to the National Cancer Center Network (NCCN) guideline for non-small cell lung cancer 
treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda to be used in combination 
with Taxol and Carboplatin. Our reviewer says that the elements of the coverage criteria are not satisfied, and 
the requested service cannot be recommended. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of stage IV non-small cell squamous carcinoma of the lung. The record indicates that 
the enrollee has had disease progression on Imfinzi and the record does not indicate that the tumor expresses 
programmed cell death ligand 1. Our reviewer found that the 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. Our physician reviewer 
also found that no literature from Medicare approved cancer journals were submitted for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda to be used in combination with Taxol and Carboplatin have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271) to be used in 
combination with Taxol (J9267) and Carboplatin (J9045).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheeled, folding walker (E0143) and walker seat 
attachment (E0156). 
 
You asked the Plan to pre-approve the walker. You say that you do not agree with the denied service for the 
folding, wheeled walker. The Plan denied your request. The Plan says the records show that you have the same 
or similar DME in good condition that was approved by the Plan on April 23, 2022. 
 
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 have walker, folding (pickup), adjustable or fixed height (E0135). The walker, folding 
(pickup), adjustable or fixed height (E0135) serves the same purpose as the walker. Therefore, we decided that 
the Plan does not have to pre-approve a wheeled, folding walker (E0143) and walker seat attachment (E0156).
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 the enrollee's complex medical needs 
and the level of care an LTACH can offer are the absolute best course of treatment. The Plan denied your 
request. The Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
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 enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility. There are no services at 
the LTACH that the patient requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is 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 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 inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve inpatient psychiatric hospitalization. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospitalization. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was 
admitted at an inpatient level of care for treatment of Substance-Related Disorder. The enrollee was not exhibiting severe withdrawal symptoms that would require inpatient withdrawal management. He had no acute 
psychiatric issues that would require inpatient care.  Inpatient admission for withdrawal management was not 
medically necessary as all of his symptoms could have been managed in a less restrictive 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 inpatient psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee has diagnoses of chronic obstructive pulmonary disease (COPD), severe obesity, obstructive sleep 
apnea noncompliant with BiPAP at home, and heart failure with preserved ejection fraction (HFpEF) with 
pulmonary hypertension. The enrollee was recently hospitalized with arterial blood gas (ABG) test consistent with acute on chronic hypercarbic respiratory failure. Endotracheal intubation was required. The enrollee 
subsequently improved on BiPAP in the hospital. Spirometry in the past has been consistent with severe 
restrictive lung disease. This enrollee may benefit from BiPAP with AVAPS during sleep as an outpatient. This 
has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings 
that can be provided by BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (PSG) (95811) split-night sleep 
study. 
 
You asked the Plan to pre-approve a PSG split-night sleep study. The Plan denied your request. The Plan says 
this request is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a follow-up PSG or home sleep test (HST) is not 
routinely indicated for patients treated with continuous positive airway pressure (CPAP), whose symptoms 
continue to be resolved with CPAP treatment. Follow-up PSG may be indicated under the circumstances listed 
in the Medicare rules section of this letter. 
 
 
  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 PSG split-night sleep study. Our 
reviewer says that a PSG split-night sleep study is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found this enrollee has a longstanding history of obstructive sleep apnea, and is currently 
compliant with CPAP. The enrollee is complaining of frequent nocturnal awakenings. The report of the most 
recent positive airway pressure (PAP) titration study on December 1, 2021, is not provided, but the clinical 
note indicates that PAP of 14 centimeters was effective. Our reviewer found that the most recent compliance 
report from December 2022 shows the enrollee is meeting compliance requirements with at least 4 hours per 
day of use on 83% of days. The apnea-hypopnea index (AHI) from the device download is 0.4 for obstructive 
events, indicating the device remains effective in controlling the sleep disordered breathing. The enrollee's 
frequent awakenings may have multiple etiologies. Our physician reviewer also found that it would be 
reasonable to address this issue by addressing sleep hygiene and adjusting medications, with a repeat sleep 
study if these measures fail. 
 
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 PSG split-night sleep study have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a polysomnography (PSG) (95811) split-night sleep study.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 21, 2021, 
to January 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from December 21, 2021, to 
January 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624). 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that you disagree with the denial. The 
Plan denied your request. The Plan says Medicare does not allow payment for experimental/investigational 
procedures. 
 
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 genicular nerve ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following, degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve 
radiofrequency ablation of the right knee 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration for tooth #3 (D4266) and 
precision attachment for tooth # 3 (D5862). 
 
You asked the Plan to pre-approve guided tissue regeneration for tooth #3 and precision attachment for tooth # 
3. You say that the services are necessary. The Plan denied your request. The Plan says the requested services 
are not a covered benefit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration for tooth #3 (D4266) and precision attachment for tooth # 3 (D5862).
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 regain maximum function and independence. The Plan denied your request. The Plan says the complexity of 
the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay. 
 
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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The enrollee can receive further services at a lower 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.