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

 
We decided that the Plan does not have to pre-approve an upgraded transmitter; external, for use with 
interstitial continuous glucose monitoring (CGM) system (A9277) and external ambulatory infusion pump 
(E0784). 
 
You asked the Plan to pre-approve a CGM transmitter and insulin pump. You say that having a CGM, if your 
blood sugar drops too low and you do not respond to the alert, it will notify your phone as well as your 
husband's phone. You are at risk of having your blood sugar drop low and the requested device will help get 
immediate care as soon as you need it. The Plan denied your request. The Plan says there is no documentation 
that current devices are malfunctioning. Per outreach to your provider's office, they confirmed that currently 
you have no issues with your transmitter or insulin pump, and they are working properly. This request does not 
meet coverage criteria as your current device is not irreparably damaged. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you currently have an insulin pump and a transmitter which serves the same purpose as the 
requested devices. The records show that both devices are working properly. Therefore, we decided that the 
Plan does not have to pre-approve an upgraded transmitter; external, for use with interstitial continuous glucose 
monitoring (CGM) system (A9277) and external ambulatory infusion pump (E0784).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fontan fenestration, atrial septal defect with implant. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational in patients over 60 years of age as it is not identified as widely used and 
generally accepted for the proposed use. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a trans-cranial doppler suggested the presence of an intermittent patent foramen ovale (PFO), but the 
patient had a transesophageal echocardiogram which showed no evidence of a PFO, nor cardiac chamber 
dilatation, evidence of cryptogenic stroke with paradoxical embolism, exertional hypoxemia or significant left 
to right shunt; nor is the patient aged 60 or less. As such, guidelines would not support the need for a PFO 
closure device. In summary, there is insufficient documentation to support the medical necessity for the 
requested PFO closure in this patients 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fontan fenestration, atrial septal defect with implant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremelimumab and Durvalumab. 
 
You asked the Plan to pre-approve Tremelimumab and Durvalumab. You say that the treatment is approved for 
metastatic lung cancer. The Plan denied your request. The Plan says the drugs are not being used in 
combination with platinum-based chemotherapy. 
 
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 Tremelimumab and Durvalumab. Our 
physician reviewer found that the enrollee has stage IVA adenocarcinoma of the lung. The FDA has not stated 
that the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's 
clinical situation. No literature from Medicare approved cancer journals were submitted for review. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tremelimumab and Durvalumab have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Tremelimumab and Durvalumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found ambulatory electrocardiogram (EKG) 
monitoring has already documented symptomatic bradycardia for this enrollee; thus, ILR implantation would 
be redundant. The documentation does not support that the ILR is 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 implantable loop recorder (ILR).
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'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 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 respiratory failure due to sepsis from 
influenza-complicating pneumonia. The record indicates that the enrollee continues to have 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 he is 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 pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the home health skilled nursing services. You say that you are appealing the 
denial of the requested services. The Plan denied your request. The Plan says two home health skilled nursing 
services were approved. The Plan cannot approve the remaining two visits. General supervision does not 
require the knowledge, judgement, and skills of a nurse according to the Plan. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 health skilled nursing 
services. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found the enrollee does not have documented skilled nursing needs. As such, the requested home 
health skilled nursing services are not medically necessary or reasonable. 
 
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 health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (36556, 77001-26 and 76937-26) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. Review of the documentation submitted does not support CPT code(s): 36556, 77001-26 and 76937-26, which was billed 
twice on date of service (DOS) July 2, 2022. Therefore, we decided that the Plan does not have to pay for the 
surgical services (36556, 77001-26 and 76937-26) provided on July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 6, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 6, 2022.
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for admission to SNF have not been met. 
 
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. 
 
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 robotic conversion of vertical sleeve gastrectomy to 
gastric bypass Roux en Y. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is experiencing daily reflux and 
gastroesophageal reflux disease. The Plan denied your request. The Plan says the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that bariatric surgery is covered for enrollees with a 
body mass index (BMI) of 35 or greater. 
 
We looked at the file and Medicare rules. The file shows that the enrollee's BMI is 30.2. 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 robotic conversion of vertical sleeve gastrectomy to gastric 
bypass Roux en Y.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS 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 there is not enough evidence showing that this requested device would improve 
outcomes. 
 
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 there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous vertebroplasty (bone biopsy included 
when performed) (22511). 
 
You asked the Plan to pre-approve Percutaneous vertebroplasty (bone biopsy included when performed) 
(22511). You say that the requested Percutaneous vertebroplasty (bone biopsy included when performed) 
(22511) is medically necessary. The Plan denied your request. The Plan says the enrollee does not met criteria 
for the requested Percutaneous vertebroplasty (bone biopsy included when performed) (22511). 
 
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 Percutaneous vertebroplasty (bone 
biopsy included when performed) (22511). Our reviewer says that the enrollee does not met criteria for the 
requested Percutaneous vertebroplasty (bone biopsy included when performed) (22511). Our physician 
reviewer found Sacroplasty is experimental. More research is needed to show safety and efficacy for 
osteoporotic sacral fractures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percutaneous vertebroplasty (bone biopsy included when performed) (22511) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous 
vertebroplasty (bone biopsy included when performed) (22511).
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 additional 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 
member to be able to control the power options using their own switches which are included in the allowance 
of these 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 additional 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 sufficient upper body strength to manage the standard 
switches. 
 
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 additional 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on current needs, care at home with home care or in a long-term facility is more 
appropriate. 
 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 that the enrollee does not qualify for SNF coverage. There are no documented skilled 
nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs are custodial and can, 
as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the documentation supports medical necessity. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on January 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 3, 2021, to 
March 6, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
provider submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. The Plan says they are upholding their decision to replace code I50.33 with I50.32 (Chronic diastolic 
(congestive) heart failure). The Plan states this recommendation results in a change from DRG 871 to DRG 
872. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with I50.3 - acute on chronic diastolic (congestive) heart 
failure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found there was no clinical or laboratory evidence of heart 
failure. The review has determined that diagnosis code I50.33 (Acute on chronic diastolic (congestive) heart 
failure) was not supported. The Plan's change from diagnosis code I50.33 to I50.32 (Chronic diastolic 
(congestive) heart failure) was more appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 3, 2021, to March 6, 2021, at the Diagnosis Related Group 
(DRG) originally billed.