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

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 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 Vertiflex device is experimental. More research is needed for this device. 
 
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 Vertiflex Superion interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01938 provided on October 25, 2022. 
 
You asked the Plan to pay for procedure code 01938. You say that the provided anesthesia (01938) was 
medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the 
provided anesthesia (01938). 
 
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 procedure code 01938. Our reviewer says 
that the enrollee did not meet criteria for the provided anesthesia (01938). Our physician reviewer found the 
review has determined that this enrollee does not have a diagnosis, condition, and/or symptoms that meet the 
Medicare criteria for coverage of monitored anesthesia care (MAC). In this case, the enrollee has no significant 
past medical history to warrant MAC. There is no documentation in the enrollee's record indicating that it is 
medically necessary to have an anesthetist/Certified Registered Nurse Anesthetist (CRNA) present during the 
L5-S1 Transforaminal Epidural Steroid Injection (TFESI). MAC is not considered the standard of care in the 
treatment of this enrollee's condition. The review has determined that it was not medically necessary or 
reasonable for this enrollee to have MAC during this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 01938 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 01938 provided on October 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not failed physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the 
requested use of Euflexxa is not supported. Our physician reviewer found the records provided do not indicate 
that the enrollee has tried and failed conservative nonpharmacologic therapy and indicate improvement with 
simple analgesics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator 
electrodes, plate/paddle, epidural (63655). 
 
You asked the Plan to pre-approve an implantation of a neurostimulator. You say that the enrollee is not a good 
candidate for a spinal fusion and has failed conservative treatments for his chronic low back pain. You say the 
enrollee is a reasonable candidate for spinal cord stimulator paddle lead placement. The Plan denied your 
request. The Plan says the requested placement of permanent spinal cord stimulator leads, is not the standard of 
care, is not medically necessary or reasonable. 
 
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 implantation of neurostimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation to show that the enrollee has had a positive result 
with pain relief from a stimulator trial. Criteria for a stimulator has 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 implantation of neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a laminectomy for implantation of neurostimulator electrodes, 
plate/paddle, epidural (63655).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the mobility scooter provided on 
September 26, 2022, by an OON provider. 
 
You asked the Plan to provide reimbursement for the scooter. You say that this scooter was medically 
necessary. The Plan denied your request. The Plan says that there was no prior authorization on file for the 
mobility scooter. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving pre-approved 
care. The Plan contract also says that certain DME may require prior authorization. 
 
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
provide reimbursement for these items/services. Therefore, we decided that the Plan does not have to provide 
reimbursement for the mobility scooter provided on September 26, 2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. 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 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 Reblozyl. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Reblozyl is not FDA-
approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. You say any lower level of care or delay in review will place the enrollee at a 
higher risk for further decompensation. The Plan denied your request. The Plan says the enrollee does not meet 
the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the clinical documentation does not completely specify functional impairments 
however, no complex functional impairments are listed. The enrollee is medically stable in a home setting; 
thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be 
expected to 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that an MRI 
is not medically necessary. Our physician reviewer found there has not been an adequate trial of physical 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the requested use of Keytruda is not approved by the 
FDA for the enrollee's diagnosis. 
 
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 Keytruda. Our reviewer says that 
Ketyruda is not medically necessary. Our physician reviewer found the record provided indicates that the 
requested drug is being used as first line therapy. The Food and Drug Administration (FDA) has not stated that 
the requested drug is indicated for the enrollee's condition as a first line therapy. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Therefore, the reviewer found that Keytruda is not medically reasonable or necessary in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
for the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found the clinical documentation shows that the enrollee has active medical 
comorbidities, but no complex functional impairments are specified. Thus, the complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 25, 2021, to 
April 26, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the DRG is not supported. 
 
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 secondary diagnosis code G93.41 (metabolic 
encephalopathy). 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 reviewer says that the submitted records do not support the billing of 
secondary diagnosis code G93.41. Our physician reviewer found the admission notes assess multifactorial 
encephalopathy; however, the enrollee's ammonia level was not elevated and the palliative care consultant 
noted limited narcotic use. The discharge note assesses acute confusion due to hepatic encephalopathy and 
makes no mention of other sources of encephalopathy. As such, the billing of G93.41 as a secondary diagnosis 
is not supported.  
 
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 April 25, 2021, to April 26, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen (HBO) therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to 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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records 
demonstrate that the revascularization was pending. Additionally, as per documented measurements your 
wound is improving with conservative wound care. The review indicates that the enrollee does not meet the 
coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen (HBO) therapy (99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the Special Supplemental Benefit for the 
Chronically Ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you feel that you meet the criteria to be enrolled in this 
benefit. The Plan denied your request. The Plan says the criteria for enrollment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not require intensive care 
management. Therefore, we decided that the Plan does not have to pre-approve enrollment in the Special 
Supplemental Benefit for the Chronically Ill (SSBCI).
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 would benefit from daily therapy 
services. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for inpatient 
rehab facility services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation does not specify any complex functional impairments. 
The enrollee is medically stable in the skilled nursing facility setting. The complexity of the enrollee's 
documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria is not 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgery services provided on June 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable 
for assistant surgery services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 20931. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgery 
services provided on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says records do not show the results of a laboratory test that measures the 
oxygen and carbon dioxide in the enrollee's arterial blood or the results of a test measuring oxygen at night that 
meet the criteria above. In addition, documentation of a trial and failure of a BiPAP machine is required, due to 
the order for VAPS settings only. The request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
COPD, and congestive heart failure. An office visit mentions a PaCO2 greater than 50, but there are no arterial 
blood gas reports provided. That note also lists a diagnosis of obesity hypoventilation syndrome. There are no 
pulmonary function tests to confirm COPD and assess severity.  If this enrollee does have severe COPD and 
chronic CO2 retention documented on an ABG done while stable, he may benefit from BiPAP with AVAPS 
during sleep. Medicare does not cover a home ventilator in the treatment of obesity hypoventilation syndrome, 
or when used at settings that can be provided with BiPAP. 
 
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 (E0466).