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

 
We decided that the Plan does not have to pre-approve the Temporarily Implanted Nitinol Device (iTind) 
procedure. 
 
You asked the Plan to pre-approve the iTind procedure. You say that this procedure is considered medically 
reasonable and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the iTind system in the setting of benign prostatic hyperplasia (BPH) with obstruction have not been 
demonstrated in the peer-reviewed literature. 
 
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 iTind procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found further studies are needed to evaluate the durability of iTind outcomes over a longer 
follow-up, to better define the indications of this approach, and to demonstrate the advantages of second-
generation device over the first device. ITind is not recommended in the most recent American Urological 
Association Guidelines regarding treatment of BPH. 
 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 iTind procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Temporarily Implanted Nitinol Device (iTind) procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is 
appropriately indicated for this patient. The Plan denied your request. The Plan says the Intracept procedure is 
considered experimental/investigational and is therefore non-covered. 
 
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 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 considered experimental at this time, and more research is 
needed before it can be considered medically necessary and 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system. 
 
You asked the Plan to pre-approve the Barostim Neo system. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and 
effectiveness of the Barostim Neo system in the setting of congestive heart failure have not been demonstrated 
int he peer-reviewed literature. 
 
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 system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is whether the requested authorization for implantation of a Barostim 
Neo system is medically necessary. Baroreflex stimulation devices have been considered potential alternative 
treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse 
generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. 
The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one 
of the carotid arteries. In August 2019, the Food and Drug Administration (FDA) approved the system for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, 
and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement 
in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. 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 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 Barostim Neo system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim Neo system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological and psychological testing coded as 
96130, 96132, 96133, 96138, 96139. 
 
You asked the Plan to pre-approve the outpatient testing. You say that you need assistance in determining if the 
enrollee's next level of care is in a memory care unit or a nursing home. The Plan denied your request. The Plan 
says the records did not support that the request for testing is reasonable or necessary at this time. 
 
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 outpatient testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review the records provided, this enrollee has had difficulty with memory 
issues and suffers from Bipolar Disorder and Major Neurocognitive Disorder, unspecified. Utilizing the criteria 
from LCD L34520, this enrollee does not meet the criteria as the enrollee makes no decisions for themselves as 
the enrollee has a guardian. The neuropsychological testing as outlined, the documentation is unclear to the 
questions needed to be answered by this testing. This enrollee makes no clinical decisions and has a guardian 
which makes decisions for them. 
 
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 outpatient testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuropsychological and psychological testing coded as 96130, 96132, 96133, 
96138, 96139.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99309 billed for date of service December 
29, 2021. 
 You asked the Plan to pay for procedure code 99309. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99309 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99309 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99309 billed for date of service December 29, 2021.
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 the enrollee's medical management and rehab needs 
require an IRF stay and close physician supervision. You say that an IRF is medically necessary for the 
enrollee to return home at their maximum level of functioning with a decreased risk for readmission. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can safely 
receive the care they need in other settings. 
 
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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that it is imperative that the enrollee gets 
transportation to their doctor's visits. The Plan denied your request. The Plan says the enrollee's plan 
supplemental benefit for one-way trips is limited to 20 for the plan year. The Plan also says that the enrollee 
has used all of their 20 one-way trips that are covered and has exhausted the benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate related to spinal fusion surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this service is medically necessary. The 
Plan denied your request. The Plan says it has approved the request for the spine surgery itself, but has denied 
the bone marrow aspirate, stating that it is not medically necessary. The clinical value and effectiveness of bone 
marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental in spinal fusion.  More research is 
needed before this can be considered medically necessary and 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate related to spinal fusion surgery.
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 enrollee would benefit from LTACH 
services. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 appears to be improving but is still somewhat unstable. The enrollee 
requires short-term additional acute care services that can safely be provided at the current facility until 
appropriate for discharge to 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you were recently 
hospitalized with worsening of chronic obstructive pulmonary disease (COPD). The venous blood gas (VBG) 
test was consistent with respiratory failure, but no arterial blood gas (ABG) was done while you were stable to 
confirm chronic carbon dioxide retention. There are no pulmonary function tests to confirm COPD. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. The home ventilator is therefore not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve conversion to gastric bypass with inpatient admission. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the records show that you have 
gastroesophageal reflux disease (GERD) after a laparoscopic vertical sleeve gastrectomy (LVSG) procedure. 
The GERD has not responded to medical management. The standard treatment after sleeve gastrectomy is 
conversion to gastric bypass. You have obtained medical clearance and failed medical management, as well as 
a LINX procedure for GERD. The inpatient level of care is the standard of care for this procedure, as it is a 
Medicare-approved inpatient-only procedure. The services are therefore reasonable and medically necessary. 
 
The rules say that inpatient only services are generally, but not always, surgical services that require inpatient 
care because of the nature of the procedure, the typical underlying physical condition of patients who require 
the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can 
be safely discharged. You can find this rule in the Centers for Medicare and Medicaid Services (CMS), 
Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 180.7. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve conversion to gastric bypass with inpatient admission.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that you have complex functional impairments and active medical comorbidities 
however your evaluating therapists and care team do not give a clear recommendation if you would be able to 
tolerate 3 hours of therapy per day as latest occupational therapy note recommends a skilled nursing facility 
and IRF.  
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (code E0265). 
 
You asked the Plan to pre-approve a total electric hospital bet. You say that the patient is receiving radiation 
treatment and she can hardly walk.  You said that she has stage 4 esophageal cancer, and she can't get out of 
bed. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (code E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement pressure powered air mattress. 
 
You asked the Plan to pre-approve air mattress. You say that the replacement mattress you were sent is not 
bariatric and you are unable to sleep at night. The Plan denied your request. The Plan says your mattress is less 
than 5 years old and is currently being repaired, so a replacement is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of durable medical equipment 
(DME) within the reasonable useful lifetime of the equipment is not covered.  
 
We looked at the file and Medicare rules. Your mattress is still within its reasonable useful lifetime and is 
currently being repaired. Based on this information, we decided that Medicare rules for coverage of air mattress 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement pressure 
powered air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system (CGM) (K0553 
and K0554). 
 
You asked the Plan to pre-approve a CGM. You say that the items are medically necessary. The Plan denied 
your request. The Plan says you do not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitoring system (CGM) (K0553 and K0554).