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

 
We decided that the Plan does not have to pre-approve an oral appliance. 
 
You asked the Plan to pre-approve an oral appliance. You say that , without the requested mouthpiece, the 
enrollee's health and well-being will decline. You say that the requested device will help prevent 
hospitalization for lack of oxygen. The Plan denied your request. The Plan says the records show that the 
enrollee does not have AHI of a minimum of 10 events per hour. 
 
The Plan must follow Medicare rules. Medicare rules say that oral appliances are only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-
approve an oral appliance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve definitive drug testing requested on October 27, 2022. 
 
You asked the Plan to pre-approve the requested drug testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says there is no documentation of the need for this definitive testing. 
 
The Plan follows Medicare rules. Medicare rules say that frequency of drug testing must be based on a 
complete clinical assessment of the individuals risk potential for abuse and diversion using a validated risk 
assessment interview or questionnaire and should include the patients response to prescribed medications and 
the side effects of 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 the requested drug testing. Our 
reviewer says that the documentation does not support that the criteria for the requested drug testing are met. 
Our physician reviewer found there were no notes showing the enrollee had an abnormal drug test in his 
doctor's office. The review has determined that the enrollee did not meet the criteria for the requested definitive 
drug testing. 
 
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 drug testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve definitive drug testing requested on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging; limited area (78814) to evaluate a compression fracture of the spine. 
 
You asked the Plan to pre-approve a PET and CT scan. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the PET and CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET and CT scan. Our reviewer says 
that a PET and CT scan is not medically necessary. Our physician reviewer found that in this case there is no 
mention of a tumor or an oncologic condition present. There is no indication of a tumor. Therefore, this request 
cannot be said to be an indication for which Medicare would cover the requested imaging modality. 
 
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 PET and CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) for attenuation correction and anatomical localization imaging; limited area (78814) to 
evaluate a compression fracture of the spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure. 
 
You asked the Plan to pre-approve the requested vascular intervention. You say that it is felt that this treatment 
is necessary. The Plan denied your request. The Plan says this procedure is not considered appropriate for the 
enrollee's condition. 
 
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 vascular intervention. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found as of July 2022, when the last angiogram was performed, the enrollee had mild 
disease in the femoral-popliteal arteries of the right leg and at that time, the right peroneal artery was 
angioplastied. The enrollee has discoloration and swelling and has been prescribed lymphatic compression 
pumps and has satisfactory perfusion such that the patient has also been prescribed compression stockings. The 
documentation does not describe limb threatening features, and there has been no follow-up ankle-brachial 
index since the right lower extremity intervention. Additionally, the enrollee has other comorbidities including 
arthritis requiring the use of a walker that limit walking distance and it is unlikely that the enrollee would experience any improvement in walking distance with further tibial interventions.  
 
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 vascular intervention have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a revascularization procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila (Q5108). 
 
You asked the Plan to pre-approve Fulphila. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says routine costs associated with this clinical trial are not 
payable. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Fulphila as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Fulphila (Q5108).
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the acute hospital can provide for all the enrollees present inpatient care needs 
and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the acute 
hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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: 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 recently had a stroke and hip fracture, 
they would benefit from IRF care. 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: 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 ventilator is medically necessary because 
the patient has tried and failed other therapies including continuous positive airway pressure (CPAP)/bi-level 
positive airway pressure (Bi-PAP). A ventilator is needed due to the severity of the patient's disease state, weak 
breathing muscles, and life-threatening condition. The Plan denied your request. The Plan says a ventilator is 
not medically necessary as the patient's condition can be treated with a Bi-PAP with average volume-assured 
pressure support (AVAPS). 
 
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 the patient has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the patient was 
successfully treated with Bi-PAP.  The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The patient could be treated with a 
Bi-PAP machine with AVAPS capability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or ct), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve the pain management injection. You say that you are appealing the denial of 
the pain management injections. The Plan denied your request. The Plan says the clinical information does not 
support that the criteria has been met for the requested procedure. 
 
 
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 pain management injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the criteria have not been met for the requested injection. Per LCD L36920 
a repeat ESI may be considered medically reasonable and necessary when the medical record documents at 
least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline 
using SAME scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat ESI 
after 14 days can be performed using a different approach, level and/or medication, if appropriate, with the 
rationale and medical necessity for the second ESI documented in the medical record. Per documentation, the 
left L1 transforaminal epidural steroid injection on September 6, 2022 worked 100% for 1-2 days and then the 
pain was the same as before. The request for a second left L1 transforaminal epidural steroid injection is not 
medically necessary as the documentation does not reveal at least 50% sustained pain relief and/or improved 
function from prior injection for at least 3 months. 
 
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 pain management injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, 
with imaging guidance (fluoroscopy or ct), lumbar or sacral, single level (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization of the left knee. 
 
You asked the Plan to pre-approve genicular artery embolization of the left knee. You say that genicular artery 
embolization of the left knee is needed as this enrollee is in pain. The Plan denied your request. The Plan says 
genicular artery embolization of the left knee to alleviate knee pain is not medically necessary and reasonable. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic embolization is covered when done for 
hemorrhage, and for other conditions amenable to treatment by the procedure, when reasonable and necessary 
for the individual patient. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular artery embolization of the left 
knee. Our reviewer says that genicular artery embolization of the left knee is not medically necessary. Our 
physician reviewer found the enrollee has osteoarthritis of the knee. The record does not indicate the presence 
of hemorrhage.  There is insufficient literature to support the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested service for the enrollee's clinical condition.  The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization of the left knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular artery embolization of the left knee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) of the brain. 
 
You asked the Plan to pre-approve a PET of the brain. 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 Medicare covers FDG Positron Emission 
Tomography (PET) scans for either the differential diagnosis of fronto-temporal dementia (FTD) and 
Alzheimers disease (AD) under specific requirements. 
 
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 PET of the brain. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the records provided for review 
indicated the presence of progressive memory problems. However, there was no documentation that the 
enrollee met diagnostic criteria for either AD or FTD--let alone both diagnoses. In this context, the requested 
service would not meet the initial requirement of the NCD. As such this service would not be 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 a PET of the brain have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) of the brain.
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 the ventilator. You say that this is necessary for the enrollee's respiratory 
condition. The Plan denied your request. The Plan says the requested type of respiratory support exceeds the 
enrollee's medical need. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically necessary at this time. Our physician reviewer found the enrollee has 
obesity-hypoventilation syndrome (OHS), likely worsened by narcotic treatment of chronic pain. She was 
admitted 9/22/22 after a fall causing back pain. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The enrollee may benefit from use of bilevel positive airway pressure (BiPAP) during sleep, but a ventilator is not covered for this purpose. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., tens, 
nmes) (procedure code A4595) provided to the enrollee on May 23, 2022. 
 
You asked the Plan to pay for the supplies. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation does not sufficiently support the billed supply code. 
 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 pay for the supplies. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is insufficient documentation of the medical necessity 
of the Zynex NexWave electrical stimulator device supplied on May 23, 2022. The provided records document 
spinal enthesopathy, thoracolumbar region; lumbar spinal stenosis; lumbar radiculopathy and lumbar 
spondylosis but the provided medical records do not document a medical need for the Zynex NexWave 
electrical stimulator device supplied on May 23, 2022.  
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) (procedure code A4595) 
provided to the enrollee on May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Orthovisc or Supartz FX. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.