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

 
We decided that the Plan does not have to pay for procedure code 36830-AS billed for date of service June 9, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the provider was an assistant during surgery. 
The Plan denied your request. The Plan says the code is included in the global surgery package for code 36833. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 36830-AS is not supported. Although assistant at surgery services are separately 
payable in this case, the code was not billed with the 80, 81, or 82 modifier as required. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 36830-AS billed for date of service June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Juvederm injection into the vocal cords. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not Food and Drug Administration (FDA) approved for laryngoplasty. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that injection of 
Juvederm into the vocal cords to help reduce the morbidity associated with sacrifice of the recurrent laryngeal 
nerve is not cited in the compendia as a medically accepted indication for use of this product. 
 
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 Juvederm injection into the vocal cords.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is enrolled in a clinical trial related to this drug, so the Plan is not 
responsible for coverage at this time. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve use of Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee has been diagnosed with 
severe obesity hypoventilation syndrome. While in the hospital, he tried and failed CPAP. He was then 
switched to BiPAP but continued to have elevated CO2 and low O2. He was then switch to NIV which treated 
his sleep disorder breathing and normalized his O2. You are asking for reconsideration as this was the only 
machine that will keep him out of the hospital. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP 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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
presumed obstructive sleep apnea, and obesity hypoventilation syndrome. There is no diagnosis of COPD, 
thoracic restrictive disease, or neuromuscular disease. The enrollee was recently hospitalized for altered mental 
status. A venous blood gas was interpreted as showing CO2 retention. However, there was no ABG, done while 
stable, to document chronic CO2 retention. If this enrollee does have chronic CO2 retention, he may benefit 
from BiPAP during sleep. This has not been tried and shown to fail as an outpatient. Medicare does not cover a 
home ventilator for the treatment of obesity hypoventilation syndrome, or 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp (S5165). 
 
You asked the Plan to pre-approve a ramp. You say that the enrollee would greatly benefit from the need of 
access ramps to their residence. The Plan denied your request. The Plan says there is no evidence that a ramp is 
medically necessary. 
 
Medicare generally does not cover ramps. However, the Plan offers a ramp benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers ramps if one of the following criteria is met: Member is wheelchair dependent and unable to enter/exit their home with assistance. 
Member has decreased ambulation skills and is unable to climb stairs. Member is only able to leave home via 
ambulance and stretcher. The member must meet one of the above criteria to be approved for a ramp. 
 
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 ramp. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation indicates that the enrollee is independent with mobility and does not 
require a wheelchair for mobility. The enrollee can climb stairs and does not leave the home via a stretcher. 
Therefore, the ramp 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 a ramp have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a ramp (S5165).
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's current condition is too 
medically complex for a lower level of care. The Plan denied your request. The Plan says there is no 
documentation that the enrollee will benefit from and improve with LTACH management. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care setting. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Yttrium-90 (Y-90) radioembolization treatment. 
 
You asked the Plan to pre-approve the Y-90 treatments. You say that it is felt that the enrollee's disease is 
amenable to Y-90 embolization. This will be a beneficial treatment. The Plan denied your request. The Plan 
says that there is insufficient support for this treatment for the enrollee's condition. 
 
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 the Y-90 treatments. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of Stage four uveal melanoma metastatic to the liver. The enrollee 
was started on a Lenvatinib/pembrolizumab clinical trial on 12/29/22. Given the pattern of the metastatic 
disease and the overall small volume of disease, Y-90 mapping and treatment are recommended. 
 
The regulation cited by the Plan, Local Coverage Article A52950, does not list any conditions as being not 
medically necessary with this treatment. National Comprehensive Cancer Network (NCCN) guidelines state 
that liver-directed embolization, including radiation can be considered for the treatment of metastatic disease. 
This therapy has been shown to be a promising treatment, and the documentation supports that is medically 
reasonable and necessary for the enrollee 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 the Y-90 treatments have been met. Therefore, we decided that the Plan has to 
pre-approve Yttrium-90 (Y-90) radioembolization treatment.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member would definitely benefit 
from the LTACH facilitys pulmonary rehabilitation, which are not available in current short term acute care 
setting. The Plan denied your request. The Plan says the LTACH services requested do not meet requirements 
for approval. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The health 
plan has approved ongoing care in the current acute care setting. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve tertiary level of care for a computed tomography (CT)-guided 
biopsy (47000, 77012). 
 
You asked the Plan to pre-approve tertiary care. You say that the requested services are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the request is 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 tertiary care. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee underwent pancreatic biopsy at the network facility on January 26, 2023, and the 
specimen had too few cells to confidently make the diagnosis of pancreatic malignancy. The liver lesions were 
vague and seen on a a positron emission tomography (PET) and computed tomography (CT) scan. Given the 
already equivocal results of the pancreatic biopsy and the vague appearance of the liver process on PET/CT, it 
is reasonable to refer a difficult imaging case such as this for biopsy under the most capable hands, which 
would likely be at a tertiary care hospital. The interventional radiologist, the pathologist and the attending 
oncologist would have the most confidence as a team in order to facilitate the needed biopsy, especially 
considering the already obtained sample of the pancreas which revealed "too few cells" to confidently make the 
diagnosis. The request for the localization of tumor under CT and the biopsy of the liver is medically necessary 
at the tertiary care center. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tertiary care have been met. Therefore, we decided that the Plan has to pre-
approve tertiary level of care for a CT-guided biopsy (47000, 77012).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823) and 
power seat elevation system (E2300). 
 You asked the Plan to pre-approve a group 2 standard power wheelchair and power seat elevation system. 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 power wheelchair and accessories are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 standard power wheelchair 
and power seat elevation system. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found your weight exceeds the capacity of the requested power wheelchair. 
 
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 group 2 standard power wheelchair and power seat elevation system have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823) and power seat elevation system (E2300).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for COVID, urinary tract infection, and syncope. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre MIS 2 continuous glucose monitor 
(CGM) reader. 
 
You asked the Plan to pre-approve a Freestyle Libre CFM reader. You say that the enrollee has type 2 diabetes 
and has lost 20 pounds in the last three months. The enrollee needs the requested CGM reader. The Plan denied 
your request. The Plan says a CGM is not covered under Medicare if the enrollee is not on insulin. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CFM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre MIS 2 continuous glucose monitor (CGM) reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal the duration or quantity of pain relief 
and/or objective functional improvement from the lumbar interlaminar epidural steroid injection at the L5-S1 
level on December 29, 2022. The documentation does not reveal that you have failed prior physical therapy 
prior to the epidural with objective documentation from 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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.