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

 
We decided that the Plan does not have to pre-approve the visual field assessment, with concurrent real time 
data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center 
for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily 
and emergent data reports as prescribed by a physician or other qualified health care professional (CPT code 
0379T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the device is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. 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 that the ForeseeHome program at issue in this case meets Medicare 
criteria for medically reasonable and necessary.  The program is unproven for improving long term results for the enrollee's condition and is considered 
experimental/investigational. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the visual field assessment, with concurrent real time data analysis and accessible data 
storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; technical 
support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as 
prescribed by a physician or other qualified health care professional (CPT code 0379T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient substance abuse admission from March 22, 
2022, through March 25, 2022. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the service was not 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 inpatient hospital care. Our physician 
reviewer found based on review the records provided the enrollee did not have any suicidal or homicidal 
ideation, auditory or visual hallucinations and was not demonstrating any response to internal stimuli. The 
enrollee's concentration was fair and thought process was logical and goal directed. In cases such as this, an 
evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of 
Care Utilization System is indispensable in determining necessary level of care for adults. In terms of Risk of 
Harm, the records support a score of one (1) due to a lack of current suicidal ideation and no self-harming 
behaviors. With regards to Functional Status, the records support a score of 1 due to minimal impairment. In 
terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 due to overall 
medical stability and low to no comorbidity. In terms of level of stress of the Recovery Environment, the 
records support a score of 1 due to a stable living situation. With regards to Level of Support for the recovery 
environment, the records support a score of 1 due to family support and availability of treatment resources but 
also some difficulty in relationships with the enrollee's family members. With regards to Treatment and 
Recovery History, the records support a score of 1 due to a significant to moderate treatment recovery 
management. In terms of Engagement and Recovery Status, the records support a score of 1 due to cooperation 
in treatment and insight into the enrollee's need for treatment along with insight into their treatment needs. 
Thus, the enrollee has a composite score of 7. This correlates with treatment in a community-based outpatient 
clinic setting. The literature indicates that outpatient treatment is appropriate for the enrollee's continued 
treatment. All told, the requested residential treatment program services are not medically necessary for the 
treatment of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient substance abuse admission from March 22, 2022, through March 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection of the low back. 
 
You asked the Plan to pre-approve an epidural steroid injection of the low back. The Plan denied your request. 
The Plan says the notes show that the enrollee had this same injection on December 3, 2021. A repeat injection 
would be approved if the pain improved by 50% for at least 3 months.  
 
The Plan follows Medicare rules. Medicare rules say that a repeat injection can be considered when the 
first injection directly and significantly provided improvement of the condition being treated. 
 
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 epidural steroid injection of the low 
back. Our reviewer says that epidural steroid injection is not medically necessary. Our physician reviewer 
found according to the coverage criteria, a repeat epidural steroid injection of the low back is indicated when 
the first injection directly and significantly provided improvement of the condition being treated 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 the same scale for at 
least three months. In this case, the enrollee had a lumbar epidural steroid injection on December 3, 2021, 
which provided > 50% relief.  The review has determined that the requested lumbar epidural steroid injection 
does not meet the Medicare LCD coverage criteria. 
 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 epidural steroid injection of the low back have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an epidural steroid injection of the low back.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 8, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo device (CPT code 0266T). 
 
You asked the Plan to pre-approve the Barostim Neo device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the Barostim Neo device is considered unproven and 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 Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollee's 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 Barostim Neo device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo device (CPT code 0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator and accessories for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator and accessories. You say that this is medically necessary. 
The Plan denied your request. The Plan says that this request is not covered. 
 
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 and accessories. Our 
reviewer says that a home ventilator and accessories is not medically reasonable and necessary. The patient was 
recently hospitalized with acute on chronic respiratory failure and improved on BiPAP. There is a diagnosis of 
COPD, but there are no pulmonary function tests to confirm. There is no evidence supporting a diagnosis of 
thoracic restrictive disease.  The patient has a diagnosis of multiple sclerosis, but there is no evidence for respiratory involvement. There is 
no evidence that BiPAP has been tried at home and failed. The average volume-assured pressure support 
(AVAPS) mode can be provided by BiPAP, and Medicare does not cover a ventilator when used as BiPAP. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home 
ventilator and accessories. 
 
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 and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator and accessories for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service December 
19, 2021. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service December 19, 
2021.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. This enrollee's 
current services can be provided in an alternate setting such as a skilled nursing facility. 
 
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 enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can be safely completed at the current facility. The 
enrollee has an overall poor prognosis. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it 
would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has 
completed.  
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex (CPT code J9145 x8 visits for a total of 568 
units). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee's chemotherapy can result in 
jeopardizing the enrollee's health. The Plan denied your request. The Plan says the documentation does not 
show medical need for this medication regimen, and it does not show that this medication regimen will be 
helpful. The Plan states there are not enough studies (in the medical literature) showing that this medication 
regimen will improve health outcomes for the enrollee's multiple myeloma without prior treatment with either 
Velcade (bortezomib), Ninlaro (ixazomib) or Kyprolis (carfilzomib). 
 
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 the medication. Our physician reviewer 
found the requested use of Darzalex (CPT code J9145 x8 visits for a total of 568 units) is not FDA-approved 
for the enrollees diagnosis because the enrollee has only received one (1) prior line of therapy. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darzalex (CPT code J9145 x8 visits for a total of 568 units).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits for a 3rd opinion from an infectious 
disease doctor. 
 
You asked the Plan to pre-approve the office visits. You say that you would like reconsideration because there 
has been a lack of clinical management with the past infectious disease doctors you have seen. The Plan denied 
your request. The Plan says this request 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 office visits. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical documentation states that you have a history of Reiter's syndrome (RS). RS is a 
group of disorders of swelling that affects organs and joints. An office visit for a 3rd opinion with Infectious 
Disease is not medically necessary for your condition. The notes do not show that the opinion of the first and 
second doctor differ. The notes do not show that you have a condition that requires antibiotics. 
 
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 office visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the office visits for a 3rd opinion from an infectious disease doctor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgical services rendered on August 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the second procedure is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the iStent device will be covered and paid as one 
unit/device. 
 
We looked at the file and Medicare rules. The file shows that the Plan covered the first iStent procedure. The 
second procedure is not separately payable. Therefore, we decided that the Plan does not have to pay for the 
outpatient surgical services rendered on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV (CPT code K0806). 
 
You asked the Plan to pre-approve the POV. You say that the POV is necessary. The Plan denied your request. 
The Plan says no medical need is shown as to why this POV is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. We looked at the file and Medicare rules. Based on this information, we decided that there is 
insufficient information in the record to determine if Medicare rules for coverage of the power operated vehicle 
(CPT code K0806). have been met. Medical records were not provided to verify medical necessity. Therefore, 
we decided that the Plan does not have to pre-approve the POV (CPT code K0806).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Ilumya. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that Ilumya 
(J3245) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our reviewer 
found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from the Plan's preferred step one alternative. Our physician reviewer also found that 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the requested 
Prolia is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet step 
therapy exception 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 Prolia. Our reviewer says that the Plan 
requires a trial of drug zoledronic acid before they will approve Prolia. Our physician reviewer found the 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from 
the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.