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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with records. The Plan denied 
your request. The Plan says the enrollee does not meet the diagnostic criteria of both Alzheimer's disease and 
frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that PET scans for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the 
records only indicated a subjective complaint of memory problems. The notes provided for review showed a 
normal mini-mental state examination (MMSE) score. There was no mention of either Alzheimer's Disease or 
frontotemporal dementia, let alone the enrollee meeting diagnostic criteria for both of these conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve phrenic nerve stimulation with the Remede system. 
 
You asked the Plan to pre-approve the system. You say that the enrollee has tried supplemental oxygen 
therapy, pharmacotherapy, continuous positive airway pressure (CPAP), and bilateral positive airway pressure 
(BiPAP) with no relief. The Plan denied your request. The Plan says that a review of the current medical 
literature indicates that this service is considered experimental and investigational as it is not identified as 
widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed 
medical literature published in the English language. 
 
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 system. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has severe central sleep apnea, without heart failure with reduced ejection fraction 
(HFrEF) and without Cheyne-Stokes breathing. This was treated with bilateral positive airway pressure 
(BiPAP) with adaptive support ventilation (ASV) which on PAP titration reduced the number of central events, 
but only from the severe to the moderate range. The patient has had difficulty tolerating the mask interface, 
despite many adjustments. The patient no longer has BiPAP because of the Phillips recall but does not want to 
continue with BiPAP. No compliance data are shown in the record, so it is not clear the patient was ever able to 
meet minimum compliance levels. The Remede system has been studied in a randomized trial of 151 patients 
with central sleep apnea (CSA) and found to be effective with a reasonable risk profile. Although more study of 
this device is needed, it is a reasonable choice for this patient because there are no other options. PAP therapy 
was not very successful and was not tolerated. 
 
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 system have been met. Therefore, we decided that the Plan has to pre-
approve phrenic nerve stimulation with the Remede system.  
 
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 pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 
(CPT code 22513) and each additional thoracic or lumbar vertebral body (22515). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show they do not 
have advanced imaging demonstrating evidence of an acute or subacute injury, or evidence of progression of 
vertebral height body loss, kyphotic deformity, or severe impact on daily functioning. 
 
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 services. Our physician reviewer 
found there are no complete physical examinations (provided for review) with subjective and objective 
findings. Additionally, there are no diagnostic imaging studies for the thoracic spine to corroborate any thoracic 
compression fractures. Without this documentation, the age of the fracture cannot be determined, the pain 
levels cannot be determined, and progression of the disc height is not able to be determined. Other causes of 
back pain cannot be ruled out. Therefore, the medical records provided do not meet the requirements listed in 
the LCD for Medicare coverage. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic (CPT code 22513) and each additional 
thoracic or lumbar vertebral body (22515).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation provided to the enrollee on September 1, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says payment is subject to recoupment as payment was rendered twice, and the records 
provided are duplicates of one angiogram right lower extremity performed. 
 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 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 documentation includes an 
extremity angiogram performed on September 1, 2021. The plan reimbursed service (claim 6822523100 to the 
provider, check number F0674047). Additional reimbursement for CPT 75710 is not supported. 
 
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 angiography, extremity, unilateral, radiological supervision and interpretation provided to the 
enrollee on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows 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 epidural steroid injection services. Our 
reviewer says that the requested epidural steroid injection services are not medically reasonable and necessary. 
Our physician reviewer found the enrollee has chronic low back pain. They take Tylenol/Codeine, 
Amitriptyline, Cyclobenzaprine, Duloxetine, Mobic and Ibuprofen. They currently have a functioning spinal 
cord stimulator (SCS) which is giving her 50% pain relief. There is no record of reprogramming attempts. 
Reprogramming the SCS should precede any other injection therapy. Further injection into the epidural space 
in the presence of a SCS is not advisable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyepti vial 100mg/ml. 
 
You asked the Plan to pre-approve Vyepti vial 100mg/ml. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Vyepti vial 100mg/ml. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the review has determined that 
the documentation does not support that the Vyepti vial 100mg/ml is medically reasonable or necessary for the 
enrollee. The documentation does not support that the Vyepti vial 100mg/ml is safe and effective for the 
enrollee 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 Vyepti vial 100mg/ml have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vyepti vial 100mg/ml.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Device. 
 
You asked the Plan to pre-approve the Vertiflex Superion Device. You say that the requested treatment is 
considered safe and effective, as supported by its clinical benefits to patients, continued medical professional 
adoption, and strong clinical evidence with numerous peer-reviewed studies. You say that the clinical 
documentation provided supports the medical necessity of the procedure. The Plan denied your request. The 
Plan says the requested procedure is unproven and not medically necessary due to insufficient evidence of 
efficacy. 
 
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 Vertiflex Superion Device. Our 
reviewer says that the Vertiflex Superion Device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex Superion Device is experimental, and 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 Vertiflex Superion Device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Vertiflex Superion Device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 1, 2022. 
 
You asked the Plan to pay for physician's services. You say that the providers rely on the nursing facility staff 
to verify eligibility and obtain authorization from the patients insurance company. The Plan denied your 
request. The Plan says the services were not urgent or emergent and the services could have been rendered by a 
Plan participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Records do not support that services in the home with home health care or 
in a long-term care facility on a part time basis are not appropriate in this case. 
 
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 SNF care.
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 the enrollee meets IRF criteria. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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 enrollees 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 that daily skilled services are not required. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. The enrollees care 
needs are custodial and intermittent, as a practical matter can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laparoscopy, surgical, esophageal sphincter 
augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including 
cruroplasty when performed (CPT code 43284). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says they cannot approve until the safety and efficacy of this LINX procedure has been 
established for patients like this enrollee. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available records however do not support the medical necessity and appropriateness of the 
LINX device. 
 
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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of 
sphincter augmentation device (ie, magnetic band), including cruroplasty when performed (CPT code 43284).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the coverage criteria 
are not met.  
The Plan follows Medicare rules. Medicare rules say that hyaluronan acid therapies are covered for the 
indications established in the applicable LCD. 
 
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 Durolane. Our reviewer says that 
Durolane is not medically reasonable and necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has osteoarthritis of the knee. The record does not indicate that the enrollee has failed 
at least three months of conservative therapy. The record provided is insufficient to demonstrate the criteria of 
the local coverage determination are satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee requires this device. The Plan denied 
your request. The Plan says a ventilator is not covered by Medicare for this purpose and there is no evidence 
that the enrollee failed use of a positive airway pressure (PAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.