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

 
We decided that the Plan does not have to pre-approve the segmental pneumatic appliance for use with 
pneumatic compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee does not have swelling of 
their chest, trunk, or abdomen. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 DME. Our physician reviewer 
found there is no documentation of any edema in the trunk or abdomen. The review indicates that the enrollee 
does not meet the coverage criteria for segmental pneumatic appliance for use with pneumatic compressor, full 
leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure 
(E0652). 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code 
E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (CPT code 22869).
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. The Plan denied your request. The Plan says admission to the IRF 
was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
Skilled nursing facility level of care was offered. 
 
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 clinical documentation shows that the enrollee has functional deficits with 
residual cerebral vascular accident (CVA) however they were previously bed bound after previous CVA and 
therapy notes do not show that they would be able to tolerate 15 hours of therapy per week. Clinical 
documentation does not show any specified active comorbidities that would require close medical monitoring 
on an inpatient basis during rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) (64483, 64484). 
 
You asked the Plan to pre-approve repeat ESIs. You say that it has been 3 months since the enrollee's last shot 
as of October 6, 2022. The Plan denied your request. The Plan says a repeat injection is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESIs. Our reviewer says that 
repeat ESIs are not medically necessary. Our physician reviewer found the previous ESI was on July 6, 2022. 
The reviewer found there is no documentation indicating at least 50% of sustained improvement in pain relief 
and/or improvement in function measured from baseline using same scale for at least three (3) months from the 
injection. Therefore, the reviewer found that repeat ESIs are 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 repeat ESIs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injection (ESI) (64483, 64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided on May 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for services. You say that you are requesting reconsideration stating that you 
inherited this patient when your old contract terminated, and you continued to provide care as per the Plan's 
standard of care until you could get credentialed. The Plan denied your request. The Plan says the enrollee must 
receive care from a network 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for services provided on May 16, 2022, by an out-of-
network (OON) provider.
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 this admission is medically necessary. The Plan 
denied your request. The Plan says prior authorization was correctly denied. 
 
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 based on medical records, the enrollee does not need skilled nursing 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction surgery. 
 
You asked the Plan to pre-approve the breast reduction surgery. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 the breast reduction surgery have been 
met. In this case, the medical records are missing information required for coverage to be made. It is noted that 
the record indicates that the plastic surgeon will discuss breast reduction once your A1C levels have fallen. 
There is no record that these levels have fallen and further discussions for surgery have been made. Therefore, 
we decided that the Plan does not have to pre-approve the breast reduction surgery.
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 will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. 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 a skilled nursing facility (SNF). 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he would 
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least three visits weekly to regain or maintain his functional status.  
 
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 Provenge. 
 
You asked the Plan to pre-approve Provenge. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says the requested drug Provenge is not approved by the Food and Drug 
Administration or listed in Medicare compendia for enrollee's condition. 
 
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 Provenge. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 74-
year-old male with a diagnosis/medical history of hormone refractory non-metastatic prostate cancer. In this 
case, the requested use of Provenge is not Food and Drug Administration-approved for the treatment of 
hormone refractory non-metastatic prostate cancer. In addition, the use of Provenge for the treatment of 
hormone refractory non-metastatic prostate cancer is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Provenge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Provenge.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bone: 1 fractions (treatment sessions) of Stereotactic 
Body Radiation Therapy (SBRT) (using photons). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found more standard forms of radiation therapy could be offered and expected to yield acceptable control of 
these metastases. SBRT would not be considered to 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bone: 1 fractions (treatment sessions) of Stereotactic Body Radiation Therapy (SBRT) 
(using photons).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
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 the home ventilator. Our physician 
reviewer found provided records document that the home ventilator is being requested for use in average 
volume assured pressure support (AVAPS) mode with auto-titration (AE) which could be provided by a 
continuous positive airway pressure (CPAP) device with AVAPS and a back-up rate. As stated in the LCD 
(L33800): Claims for ventilators used to provide CPAP or bi-level continuous positive airway pressure 
(CPAP) therapy for conditions described in this RAD 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardant 360 CDx Liquid Biopsy (0242U). 
 
You asked the Plan to pre-approve Guardant 360 CDx Liquid Biopsy. You say that this testing is needed to 
guide future treatment decisions. The Plan denied your request. The Plan says the records do not indicate how 
results of the test will change the management or treatment of your cancer. 
 "The Plan follows Medicare rules. Medicare rules say that the enrollee must meet the criteria listed in the 
Medicare Rules section of this letter in order for Guardant360 CDx Liquid Biopsy to be 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 Guardant 360 CDx Liquid Biopsy. Our 
reviewer says that the requested testing is not medically necessary. Our physician reviewer found that in this 
case the enrollee has metastatic adenocarcinoma of the prostate. The submitted records do not indicate whether 
the enrollee has been tested with Guardant36 for the same genetic content nor do they indicate whether the 
enrollee is responding to current treatment. The enrollee has not decided to seek further cancer treatment with a 
drug that is FDA approved or has a NCCN or NCCN 2A recommendation for the enrollee's cancer. 
Additionally, it is not shown that tissue based comprehensive genomic profiling CGP is infeasible or has shown 
no actionable mutations. Therefore, the enrollee does not meet the requirements for coverage of Guardant 360 
CDx Liquid Biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Guardant 360 CDx Liquid Biopsy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Guardant 360 CDx Liquid Biopsy (0242U).
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 this admission is medically necessary. 
The Plan denied your request. The Plan says a LTACH admission has been correctly denied. 
 
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 all the enrollee's medical needs care being provided 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dialysis services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the services were approved to an in-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the dialysis 
services to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 23, 2022, 
to April 10, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you are requesting an appeal for the 
cost share applied to the SNF stay. You say that a new benefit period should apply. 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 $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for a skilled nursing facility stay.  
 
 
  You have been asked to pay a total copayment of $2,632 for a SNF stay. However, during the processing of 
this claim, your maximum out-of-pocket was met leaving a remaining copayment of $1,522. This item/service 
falls within the Skilled Nursing Facility (SNF) Care 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 a SNF stay provided from March 23, 2022, to April 10, 2022.