Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation or replacement of carotid sinus baroreflex 
activation device; total system (0266T) and a generator, neurostimulator (implantable), non-rechargeable with 
carotid sinus baroreceptor stimulation lead(s) (C1825). 
 
You asked the Plan to pre-approve a Barostim system implant. You say that the device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested service is not covered by Medicare 
or the health plan. Experimental procedures and items are those items and procedures determined by our plan 
and Original Medicare to not be generally accepted by the medical community. 
 
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 Barostim system implant. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator 
implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse 
generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the 
carotid arteries. In August 2019 the FDA approved the system for use in patients with refractory heart failure 
who remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have 
an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical 
study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this 
time the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Barostim system implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation or replacement of carotid sinus baroreflex activation device; 
total system (0266T) and a generator, neurostimulator (implantable), non-rechargeable with carotid sinus 
baroreceptor stimulation lead(s) (C1825).
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 enrollee is not ready to go back to a skilled 
nursing facility and still needs care in an inpatient facility. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as at home 
with home services including nursing for clinical monitoring, wound care, physical therapy, and occupational 
therapy. 
 
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 chronic obstructive pulmonary disease (COPD) 
exacerbation. The enrollee's medical problems are stable, and 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (known as US-IGRT) (G6001) and radiation treatment delivery, superficial and/or ortho voltage, per day 
(77401). 
 
You asked the Plan to pre-approve ultrasonic guidance and radiation treatment. You say that you disagree with 
the denial; it is medically necessary for the enrollee. The Plan denied your request. The Plan says US-IGRT is 
not medically necessary for superficial radiation therapy. The request does not meet the Medicare or health 
plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ultrasonic guidance and radiation 
treatment. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found IGRT is a means to improve set-up accuracy. IGRT uses 
daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT 
allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be 
reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used 
when critical structures are abutting or in close proximity to the target that is being treated to high doses. This 
situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set 
up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for 
daily simple simulations and/or IGRT for a technology for which need has not been established by published 
data or supported by consensus guidelines is not necessary. The decision is unfavorable as billing for daily 
IGRT or daily simulations (also requested in this case) would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance and radiation treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy fields 
(known as US-IGRT) (G6001) and radiation treatment delivery, superficial and/or ortho voltage, per day 
(77401).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CalaTrio device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that peripheral nerve stimulation is covered when 
specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested CalaTrio device is not 
readily used for pain/pain management purposes. The available literature on the CalaTrio device is largely 
limited to studies published by the device's manufacturers. The studies have all had significant methodological 
limitations as identified by their authors. These limitations also present a need for further study and 
confirmation to determine the overall efficacy of the technology. There is also a need for studies of the technology to be done to determine its comparative efficacy to other established therapies for the condition. 
The services do not meet the criteria for coverage and are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CalaTrio device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair accessory, solid (rubber/plastic) 
caster tire with integrated wheel, any size, replacement only, each (E2392). 
 
You asked the Plan to pre-approve the tire replacement. You say that the power wheelchair is in your bedroom 
so that you may go to the bathroom. You need this equipment immediately because you use the equipment. The 
Plan denied your request. The Plan says report from may indicated that the current power wheelchair is not 
safe, and the enrollee should be using a scooter. Since the enrollee will be safer in a scooter, unable to provide 
parts for equipment that the enrollee is not safe in.  
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 tire replacement. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the plan denied because a scooter is deemed safer than a power wheelchair. The 
current power wheelchair is not safe and therefore cannot replace a part for equipment that is unsafe. 
 
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 tire replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the power wheelchair accessory, solid (rubber/plastic) caster tire with integrated 
wheel, any size, replacement only, each (E2392).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the certain requirements are 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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
previous epidural steroid injection on October 4, 2022, provided 50% pain relief for only 2 weeks. 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 cardiac catheterization. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the medical records provided reflect that the enrollee is without chest pain, described as 
stable, and with a recent stress test negative for ischemia. The guidelines do not support a need for cardiac 
catheterization in the enrollee's clinical 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 31, 2021, to 
April 2, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that acute 
respiratory failure with hypoxia is supported by documentation within the medical record and is a valid 
assigned diagnosis. The Plan denied your request. The Plan says the hospital record does not support reporting 
the diagnosis code for acute respiratory failure with hypoxia. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.21 acute respiratory failure with hypoxia. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the medical records did not support the DRG as billed. Our physician 
reviewer found in this case there was no clinical documentation of acute respiratory failure with hypoxia.  The 
enrollee, with a history of hypertension, diabetes, hypothyroidism, hyperlipidemia, some form of esophageal 
surgery after drinking Drano, who presented to the ED on March 31, 2021, with complaints of shortness of 
breath. The enrollee apparently noted right chest wall pain as well as shortness of breath yesterday and the 
symptoms progressively worsened. The enrollee complained of a cough that was somewhat productive of a 
clear to yellow sputum. The enrollee did admit to exertional dyspnea as well as orthopnea. Chest x-ray revealed 
bilateral infiltrates. The enrollee had this interesting linear line at count of traces the lateral lung. It was 
suggested by the ED doctor that this might be related to the esophageal surgery. No labs are pending at this 
point except for an ABG and a troponin. It was documented in the patient care section that the enrollee had a 
saturation of 88% on arrival. The review has determined that the medical records did not substantiate the DRG 
as billed. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 31, 2021, to April 2, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation on June 3, 
2022, to June 6, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for outpatient hospital observation.  
 
You have been asked to pay a $375 copayment for outpatient hospital observation. This item/service falls 
within the outpatient hospital observation benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient hospital observation on June 3, 2022, to June 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan 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 Ondansetron.  
 
Benefits for Ondansetron 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 an expandable controller and related electronics (E2377, 
E2313, E2311). 
 
You asked the Plan to pre-approve an expandable controller and related electronics. You say that this 
equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this 
equipment is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 an expandable controller and related 
electronics. Our reviewer says that this equipment is not medically reasonable and necessary. Our physician 
reviewer found the enrollee has very good upper body strength and mobility. He has the capacity to manage 
multiple standard controls on a power wheelchair. 
 
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 expandable controller and related electronics have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related electronics (E2377, 
E2313, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2021, billed with 
codes 81225, 81226, 81230, 81240, 81241, 81291, 81335, and 81406. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 19, 2021, billed with codes 81225, 81226, 81230, 81240, 81241, 81291, 81335, and 81406.
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 a home ventilator is medically necessary 
because you need it to breathe and your life depends on it. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for you. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found based on the medical records 
provided there is documentation that you have chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document that the home ventilator is being requested for use in 
intelligent volume assured pressure support mode with auto-titration which could be provided by a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support and a back-up rate.  As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this policy will be 
denied as not reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.