Persius/hicric huggingface dataset:
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 admission allows for the highest 
potential level of recovery. The Plan denied your request. The Plan says LTACH admission is not medically 
necessary as the patient can continue to receive acute care services at the current 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 the patient is an 87 year-old male who was admitted to the acute care hospital with 
pneumonia, congestive hear failure, recent COVID-19 infection, and acute respiratory failure requiring high 
flow oxygen support, IV steroids, antibiotics, bronchodilators. Recent notes describe the patient as gradually 
requiring less oxygen but still on high flow and still with fever. The patient appears to still be somewhat 
unstable and requires short-term additional acute care hospital services that can safely be completed at the 
current facility until more stable and more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as the patient is not yet stable for transfer and as it would not be clinically advantageous. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641) billed on March 11, 2022. 
 
You asked the Plan to pay for the breast ultrasound (76641). You say that the services were billed appropriately 
and are supported in the record. The Plan denied your request. The Plan says the services are not supported as 
billed and there is a more appropriate code for the services performed. A study that does not include all four 
quadrants of the breast, the retroareolar region and examination of axilla should be considered limited. 
 
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, the CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the breast ultrasound (76641). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the radiology report does not include enough information to confirm a complete breast ultrasound has been 
performed. A study that does not include all four quadrants of the breast, the retroareolar region and 
examination of axilla should be considered limited. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the breast ultrasound (76641) have not been met. Therefore, we decided that the 
Plan does not have to pay for the breast ultrasound (76641) billed on March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar artificial disc replacement (LADR) surgery for 
levels L3-L4, L4-L5, and L5-S1. 
 
You asked the Plan to pre-approve the multiple level LADR procedure. You say that this should be approved as 
it will help the enrollee's pain and increase function. The Plan denied your request. The Plan says this is 
experimental if done at more than one spinal level. 
 
The Plan follows Medicare rules. Medicare rules say that LADR devices have been approved for use at no 
more than one spinal level. Individual consideration is given to coverage for enrollees 60 years of age or less. 
 
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 multiple level LADR procedure. 
Our reviewer says that the requested procedure is not medically reasonable and necessary at the number of levels requested. Our physician reviewer found lumbar disc replacement at multiple lumbar levels remains 
experimental. More research is needed to show safety and efficacy 
 
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 multiple level LADR procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve lumbar artificial disc replacement (LADR) surgery for levels L3-L4, 
L4-L5, and L5-S1.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the wound does not require 
skilled nursing services. Evidence that the enrollee is home bound was not provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2017 billed for date of service February 24, 
2022 to February 25, 2022. 
 
You asked the Plan to pay for procedure code H2017. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code H2017 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2017 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code H2017 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2017 billed for date of service February 24, 2022 to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis (L1690) provided on March 14, 2022. 
 
You asked the Plan to pay for the hip orthosis. You say that you would like this claim reprocessed based on the 
documentation that has not been submitted. The Plan denied your request. The Plan says documentation 
required for payment is missing. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not indicate that the ordering provider discussed the need for 
the ordered orthosis with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the hip 
orthosis (L1690) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections provided from March 11, 2022, to 
March 25, 2022. 
 
You asked the Plan to pay for facet joint injections. You say that the facet joint injections were medically 
necessary. The Plan denied your request. The Plan says the facet joint injections were not medically necessary. 
 
The Plan follows Medicare rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for facet joint injections. Our reviewer says that 
the facet joint injections are not medically necessary. Our physician reviewer found that the documentation 
does not reveal that there is no non-facet pathology per clinical assessment or radiology studies that could 
explain the source of your pain. The documentation notes that you had a cervical epidural on March 11, 2022 
due to neck pain, upper extremity dysfunction, numbness and tingling. The cervical MRI on January 24, 2022 
reveals multilevel severe degenerative changes resulting in multilevel severe neural compromise. Additionally, 
there is flattening of the cervical cord on the MRI at C7-8. You also describes gait imbalance and there is a 
positive Hoffman sign. The provider notes that you have myelopathy. The requested facet joint injections at 
issue in this case do 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pay for facet joint injections provided from March 11, 2022, to March 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on December 2, 
2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for colorectal cancer. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on December 2, 2021.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Alimta. 
 
You asked the Plan to pre-approve Alimta. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says that Alimta must be used as initial (first-line therapy) when used in 
combination with Keytruda and carboplatin. 
 
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 Alimta. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found the enrollee is status post 
adjuvant chemotherapy with carboplatin/Alimta for stage III non-small cell lung cancer. They were initially 
treated with oral Kirsten rat sarcoma virus (KRAS) inhibitor and have experienced progression. In this case, 
there is support for the requested drug in the National Comprehensive Cancer Network compendia. Per 
Medicare compendium, this request is medically reasonable and 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 Alimta have been met. Therefore, we decided that the Plan has to pre-approve 
Alimta.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft vertebral disc. 
 
You asked the Plan to pre-approve an allograft vertebral disc. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the available scientific 
evidence does not support conclusions regarding safety, effectiveness, and net outcomes of requested 
allogeneic services. 
 
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 allograft vertebral disc. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 54-year-old woman with chronic low back pain. In this case, the 
requested procedure is an experimental/investigational therapy. Therefore, the request is deemed not medically 
reasonable or 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 an allograft vertebral disc have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an allograft vertebral disc.
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 admission is medically 
necessary. The Plan denied your request. The Plan says criteria for LTACH admission 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 patient is a 57 year old male on home oxygen support (5L/m) who was admitted 
to the acute care hospital with acute respiratory failure, Chronic obstructive pulmonary disease exacerbation in 
the setting of autoimmune vasculitis history. He required BiPAP, diuretics, steroids, and bronchodilators. 
Recent notes describe the patient as still requiring high flow oxygen support, IV steroids. The patient appears to 
be more stable and gradually improving but requires short-term additional acute care hospital services that can 
safely be completed at the current facility until more stable and appropriate for a lower level of care. The 
patient does not require services at the LTACH that are not already 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the member does not meet SNF criteria and can be managed at a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that SNF 
care is not medically necessary. Our physician reviewer found the member has a previous stroke and functional 
impairment. She has not responded to intensive rehabilitation with significant material change in transfers and 
lower body activities of daily living. She does not show capacity to respond to daily skilled therapy within a 
reasonable time frame.She may well need more time as she has persistent lower body weakness which impairs 
her capacity, but she cannot respond within a predictable time frame 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you were independent prior to your surgery and now 
you need assistance with every part of your daily living. The Plan denied your request. The Plan says you do 
not meet Medicare criteria for SNF coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that SNF 
care is not medically reasonable and necessary. Our physician reviewer found you are functioning at the 
expected level following by-pass and are at home care level. You are able to improve stamina and endurance 
with repetitive exercise with non-skilled stand by support. Daily skilled services are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the service is medically necessary. Our physician reviewer found you have functional loss in setting of 
dementia and acute illness. There are no records indicating that you cannot respond to daily skilled therapy. 
Your hospital stay is an acute illness and is an indication for daily skilled therapy to address functional 
impairment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued skilled nursing facility (SNF) care.  
 
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 therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that the requested CGM is medically 
reasonable and necessary for your condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).