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

 
We decided that the Plan does not have to pre-approve surgery to remove excess tissue from the neck. 
 
You asked the Plan to pre-approve surgery to remove excess tissue from the neck. 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 liposuction used for body contouring, weight 
reduction or the harvest of fat tissue for transfer to another body region for alteration of appearance or self-
image or physical appearance is considered cosmetic and not covered as 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 surgery to remove excess tissue from 
the neck. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
clinical documentation does not support that you have a medical condition for which reconstructive surgery is 
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 surgery to remove excess tissue from the neck have not been met. Therefore, we 
decided that the Plan does not have to pre-approve surgery to remove excess tissue from the neck.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Cardiac Contractility Modulation (CCM) 
smart 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Optimizer smart device was 
approved by the Food and Drug Administration (FDA) in 2019 and 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. The Optimizer smart device is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Optimizer Cardiac Contractility Modulation (CCM) smart device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A Negative Pressure Wound Therapy (NWPT) pump 
(E2402). 
 You asked the Plan to pre-approve a NWPT pump. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a NPWT pump and supplies will be denied as not 
reasonable and necessary with any of the conditions listed in the Medicare Rules section, whichever occurs 
earliest. 
 
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 NWPT pump. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the wound continues to enlarge despite 
appropriate management. The review has determined that in the judgment of the treating practitioner, adequate 
wound healing has not occurred to the degree that NPWT may be discontinued. 4 months (including the time 
NPWT was applied in an inpatient setting prior to discharge to the home) have elapsed using a NPWT pump in 
the treatment of the most recent wound. 
 
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 NWPT pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve A Negative Pressure Wound Therapy (NWPT) pump (E2402).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months for oxygen equipment. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says no 
additional rental authorizations can be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made.  
 
 We looked at the file and the rules. The records show that 36 months of rental payments will conclude as of 
August 26, 2023. The supplier who provided the equipment during the 36th rental month is required to 
continue to provide the equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen 
equipment during the 5-year reasonable useful lifetime of the equipment. Therefore, we decided that the Plan 
does not have to pre-approve additional rental months for oxygen equipment.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that there is no practicing dermatologist that would use 
Infectra or Remicade as first step therapy. You say that doing so could expose the enrollee to a higher risk of 
complications or side effects. You also say that the requested drug is necessary for the enrollee's treatment. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Remicade, 
Inflectra or Infliximab; and Stelara. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs. The reviewer found that the record does not indicate 
that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred drugs. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sock slider (A9270), and a reaching/grabbing device 
(A9281). 
 
You asked the Plan to pre-approve a sock slider and a reaching/grabbing device. The Plan denied your request. 
The Plan says these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a sock slider (A9270), and a reaching/grabbing device 
(A9281).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
accessories (E0657, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related accessories. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for PCDs have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and related accessories (E0657, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Zip arthrodesis device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is 
considered experimental and 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 the requested services. Our physician 
reviewer found that the Aurora Zip device is experimental in spine surgery. More research is needed to show its 
safety and efficacy. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Aurora Zip arthrodesis device.
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 benefit from the services to help 
them rebuild their strength and mobility. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee is not stable 
for transfer out of the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic hypoxic and hypercapnic respiratory 
failure secondary to multifocal pneumonia. The record indicates that the enrollee has ongoing acute medical 
issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not 
currently receiving but that would be available at the LTACH facility. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided April 13, 2022, to May 
12, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 13, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services provided April 13, 2022, 
to May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member's current health condition 
requires an LTACH admission. The Plan denied your request. The Plan says the member does not meet the 
criteria for an LTACH admission. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that are not currently being 
received, but that would be available at the LTACH facility. The requested service cannot be recommended, as 
the elements of the coverage rules are not 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 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the medical supplies (A4351) provided on April 7, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that this charge is 
incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that this charge is incidental to another service. However, the 
Plan has not indicated which service this item is incidental to, nor has it provided documentation of another 
service billed on the same date. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the medical supplies (A4351) provided on April 7, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Rush Rogue prosthetic foot. 
 
You asked the Plan to pre-approve prosthetic foot. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee is not a level 3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules state that coverage of lower limb prosthetics is based on an 
assessment of the enrollees functional level. 
 
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 prosthetic foot. Our reviewer says that 
the enrollee does not meet criteria for this prosthetic foot. Our physician reviewer found the documentation 
does not support that the enrollee is a level 3 ambulator and therefore the requested level 3 foot is not 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 prosthetic foot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Rush Rogue prosthetic foot.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
testing is not medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that Factor 5 (F5) and Factor 2 (F2) gene testing was requested. 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 requested testing. Our physician reviewer found that the 
enrollee has a diagnosis of a dural sinus thrombosis with a history of head injury with skull fractures from March 2022.  The provided medical records and review of the current peer-reviewed medical literature do not 
support that the testing is medically indicated. Routine testing for hypercoagulable disorders in those with a 
diagnosis of venous thromboembolism is not warranted in the absence of certain clinical factors such as 
recurrent thromboses or cerebral vein thrombosis without predisposing factors. A head injury is a predisposing 
factor for cerebral vein thrombosis. There is no documentation that the F5 and F2 gene testing at issue in this 
case meets all Medicare criteria for medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum assisted socket system (VASS) (L5781). 
 
You asked the Plan to pre-approve a VASS. You say that this is covered by Medicare. You say that this is 
medically necessary for him as a very high functioning amputee to prevent volume fluctuation which could 
cause the prostheses and the residual limb to lose total contact which would cause instability resulting in patient 
falling. The Plan denied your request. The Plan says a VASS 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 a VASS. Our reviewer says that the 
requested VASS is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the VASS in randomized controlled trials has not been found to significantly improve function. 
Therefore, the reviewer found that the reqeusted VASS 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 a VASS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a vacuum assisted socket system (VASS) (L5781).