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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of the power 
options. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has adequate upper body strength to manage standard switches for the multiple 
power drives. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization of 
the iliac artery (37225, 37226, 37224, 37221, 37227, 37228, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization of the iliac artery. 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 PTA is covered when used under certain conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lower extremity angiography and 
revascularization of the iliac artery. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for iliac artery 
lower extremity angiography and revascularization 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 lower extremity angiography and revascularization of the iliac artery have not 
been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity angiography and 
revascularization of the iliac artery (37225, 37226, 37224, 37221, 37227, 37228, 37229, 37230, 37231).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
continued admission to a SNF. The Plan denied your request. The Plan says the request for continued 
admission to a SNF is not shown to be medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is 
medically stable now and are getting better and can be safely treated in a less intensive setting 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is 
medically stable and does not require three physician visits a week, documentation stated limited endurance 
and continued therapy services can be provided at a lower level of care, a skilled nursing 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty (22513). 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 vertebroplasty/kyphoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
show that the fracture is less than 6 weeks old. There are no imaging studies showing an acute fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty/kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertebroplasty/kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, combined posterior or posterolateral 
technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 
interspace (22633),  allograft, morselized, or placement of osteopromotive material (20930), a bone marrow 
aspiration for bone grafting (20939), an insertion of interbody biomechanical device(s) (22853), a posterior 
non-segmental instrumentation (22840), a laminectomy, facetectomy, or foraminotomy (63052) and a 
stereotactic computer-assisted (navigational) procedure (61783). 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the enrollee is scheduled for surgery 
April 4, 2023. You have attached additional records/clinicals to support the request for medical necessity. The 
Plan denied your request. The Plan says the request does not meet the Medicare or health plan coverage 
criteria. Medicare covers medically necessary services. Those are services needed to diagnose or treat a 
medical problem and that doctors agree are standard medical care. There are not enough studies to show it is 
safe and effective. 
 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 spinal fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found spinal fusion surgery is not medically needed. The imaging studies show lumbar 
stenosis without instability. Fusion surgery is not the best option for back pain with spinal stenosis without 
instability. Only decompression 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, combined posterior or posterolateral technique with posterior 
interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (22633),  
allograft, morselized, or placement of osteopromotive material (20930), a bone marrow aspiration for bone 
grafting (20939), an insertion of interbody biomechanical device(s) (22853), a posterior non-segmental 
instrumentation (22840), a laminectomy, facetectomy, or foraminotomy (63052) and a stereotactic computer-
assisted (navigational) procedure (61783).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic assisted therapy device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show limited left shoulder and elbow range of motion in the left arm, and 
significant skin scarring of the left arm. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device has not been shown to be reliably effective for an enrollee decades post-injury and in 
setting of burns with extensive scarring. The enrollee is very active and able to function well with his current 
cable driven prosthesis. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a robotic assisted therapy device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve a lumbar facet joint RFA procedure. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria.  
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 lumbar facet joint RFA procedure. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD 
requires two sets of diagnostic medial branch blocks (MBBs) which produce 80% or greater pain relief. Only 
one set is documented here. Therefore, at this time, the request is deemed 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 lumbar facet joint RFA procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA) procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 CardioMEMS procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered experimental. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure (33289, C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (77014, 77370, 77470, 
77520, 77522, 77523, 77525, G6002). 
 
You asked the Plan to pre-approve Proton Beam Radiation Therapy. You say that PBT is medically necessary 
for the enrollee. The Plan denied your request. The Plan says 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 Proton Beam Radiation Therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient prospective, long-term clinical data available to 
determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent 
to external beam radiation therapy, IMRT, or brachytherapy with regards to safety and efficacy. Recent data 
shows no significant differences in late (years one, two, and three) enrollee-reported toxicity outcomes between 
proton beam therapy and IMRT. The most recent AUA and NCCN guidelines state that PBT offers no clinical 
advantage over other forms of definitive treatment. According to NCCN and ASTRO guidelines, proton beam 
therapy may be offered to individuals enrolled in an IRB approved prospective clinical trial or multi-
institutional registry that adheres to Medicare requirements for CED. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Radiation Therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Proton Beam Radiation Therapy (77014, 77370, 77470, 77520, 77522, 
77523, 77525, G6002).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the PBRT (77014, 77370, 77387, 77470, 77523). 
 
You asked the Plan to pre-approve the PBRT. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the proton therapy would be 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 PBRT have been met. Therefore, we decided that the Plan has to pre-
approve the PBRT (77014, 77370, 77387, 77470, 77523).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on May 
16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the imaging showed no acute 
findings, vitals were stable, physical findings were unremarkable other than the facial droop and weakness on 
left side. Magnetic resonance imaging (MRI) was ordered. Based on the provided documentation, although 
there was support for a complete history and examination, it was not comprehensive, and the decision making 
was not of high complexity. It was rather of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) (E0601) 
device and heated humidifier (E0562). 
 
You asked the Plan to pre-approve a continuous positive airway pressure (CPAP) (E0601) device and heated 
humidifier (E0562). You say that the requested continuous positive airway pressure (CPAP) (E0601) device and heated humidifier (E0562) are medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested continuous positive airway pressure (CPAP) (E0601) device 
and heated humidifier (E0562). 
 
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 continuous positive airway pressure 
(CPAP) (E0601) device and heated humidifier (E0562). Our reviewer says that the enrollee does not meet 
criteria for the requested continuous positive airway pressure (CPAP) (E0601) device and heated humidifier 
(E0562). Our physician reviewer found based on the medical records provided there is no documentation that 
the enrollee meets the LCD criteria for the requested ongoing use of the continuous positive airway pressure 
(CPAP) (E0601) device and heated humidifier (E0562). Provided records in this case do not document an in-
person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep 
apnea are improved and objective evidence of adherence to use of the PAP device, reviewed by the treating 
practitioner as required by 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 a continuous positive airway pressure (CPAP) (E0601) device and heated 
humidifier (E0562) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous positive airway pressure (CPAP) (E0601) device and heated humidifier (E0562).