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

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging 
guidance (ie, fluoroscopy or CT) (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee had one injection on August 4, 2022, 
that gave them at least 50% relief. You state that was more than two weeks ago. You state outpatient procedure 
fluoroscopy imaging will be performed during the injection and the injection is part of an existing treatment 
plan, series of three injections. The Plan denied your request. The Plan says the clinical information provided 
does not describe the level(s) to be treated or exceeds the limits, and therefore, the requested procedure is not 
indicated at this time. 
 
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 injection. Our physician reviewer 
found the review indicates that the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or 
CT) (CPT code 62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipilimumab (CPT code J9228) and Nivolumab (J9299). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says there is not sufficient scientific literature to indicate the combination therapy of 
Nivolumab and Ipilimumab is medically necessary and has not been shown to improve outcomes. 
 
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 Ipilimumab 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ipilimumab (CPT code J9228) and Nivolumab (J9299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart device (CCM) (CPT code 0408T). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this device is not approvable by the enrollee's Plan because it is still being studied to see 
if it is as good as or better than the standard treatment for heart failure. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CCM remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, our 
physician reviewer would not consider the CCM system to be medically necessary in 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart device (CCM) (CPT code 0408T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special power wheelchair (group 3 power 
wheelchair) with two (2) or more power seat options - power tilt and power seat lift (called a power seat 
elevation feature) (CPT code(s): K0861, E2300, E2311, E2361, E2377, E1010, E2607, E1028, K0108, E2613, 
E1002, E2313, E0955). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary based on Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer found there is no documentation that the enrollee meets criteria for the requested group 3 power wheelchair 
with multiple power options (power tilt and a power seat elevation feature). The power seat elevation feature is 
statutorily non-covered as it serves no primary medical purpose. As the power seat elevation feature does not 
meet criteria, the multiple power options do not meet criteria for coverage. The enrollee appears to meet criteria 
for a group 3 power wheelchair with a single power option. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the special power wheelchair (group 3 power wheelchair) with two (2) or more power seat 
options - power tilt and power seat lift (called a power seat elevation feature) (CPT code(s): K0861, E2300, 
E2311, E2361, E2377, E1010, E2607, E1028, K0108, E2613, E1002, E2313, E0955).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in constant pain. You state the 
procedure is needed for the enrollee's safety. The Plan denied your request. The Plan says the enrollee's request 
is not medically necessary because their records show there is not a question as to whether or not the enrollee 
has atrial fibrillation currently. The Plan states there is no evidence that the results of this test will change the 
enrollee's medical management. 
 
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 evidence that the implantable loop reader (ILR) results would change the enrollees 
medical management. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs admission to LTACH. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition they do not meet all the requirements. 
 
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 to the acute care hospital with esophageal perforation in 
the setting of acute on chronic vomiting complicated by pneumomediastinum and treated with thoracotomy and 
medias tonal exploration with drainage, esophageal stent, chest tube, intravenous antibiotics, and jejunostomy 
and gastric tube placements. The course was complicated by septic shock, pulseless electrical activity, 
pneumonia, and delirium. Recent notes describe the patient as still requiring sitter and restraints for delirium, 
but kidney function improved and vital signs are stable with antibiotics completed.  
 The enrollee appears to be improving but is not yet stable (delirium) and requires additional short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not available 
at the current 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that you could go into respiratory failure and 
possibly die because of the large retention of carbon dioxide (CO2). The Plan denied your request. The Plan 
says your request is not medically necessary because your records show you had adequate oxygen saturation 
levels (given your baseline chronic hypoxic respiratory failure) when using a bilevel positive airway pressure 
(BiPAP) device with supplemental oxygen. The Plan states your blood oxygen levels using a BiPAP with 
supplemental oxygen are like what your baseline awake oxygen levels are at your doctors office. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found the record indicates that you have chronic respiratory failure from chronic obstructive 
pulmonary disease and obstructive sleep apnea. The record indicates that you were successfully treated with 
BiPAP. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee is unhappy with their 
current cardiologist and prefers to see their previous cardiologist who has known and treated the enrollee for 
several years. The Plan denied your request. The Plan says there is an in-network provider that can perform the 
services the enrollee needs. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH. The Plan denied your 
request. The Plan says rules for LTACH care have not been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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. You say that you want to move the enrollee to another facility that 
is more geared to therapy so that they can get the enrollee stronger and get her home. The Plan denied your 
request. The Plan says based on Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services you 
and/or your provider 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 based on clinical documentation, the patient has multiple medical comorbidities and 
functional impairments, but there is no documentation that shows the patient requires or can tolerate intense 
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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 in this case the enrollee was admitted with sepsis in the setting of acute cholecystitis. 
The record indicates that the enrollee is improving but still require acute care services before transitioning to a 
lower level of care. 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. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an in-network tertiary 
care provider. 
 
You asked the Plan to pre-approve the office visit. You say that you need a review of your blood level count 
because you have a blood condition that indicated there may have been pre-cancer. The Plan denied your 
request. The Plan says they do not believe that your diagnosis meets the criteria for a high level of care. 
 
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 visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found your health problems are being managed with observation alone and are common hematology 
issues managed easily by non-tertiary hematology/oncology physicians. Care by a tertiary care provider is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the office visit to be provided by an in-network tertiary care provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee was admitted with squamous cell carcinoma of the head 
and neck region and underwent operative intervention. The record indicates that the enrollee still requires acute 
care services such as antibiotics and high flow oxygen and is unstable for transitioning to a lower level of care 
of service. 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. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the back intracept procedure (CPT code(s): 64628 and 
64629). 
 
You asked the Plan to pre-approve the back intracept procedure. You say that the enrollee's spinal problem has 
made doing most things very difficult. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for their back pain. The Plan states it is not an accepted standard of medical practice for 
the diagnosis or treatment of back pain and it is considered experimental and 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 back intracept procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the intracept procedure is experimental. More research 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 the back intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the back intracept procedure (CPT code(s): 64628 and 64629).