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

 
We decided that the Plan does not have to pre-approve the implantation of a replacement LOOP recorder 
(33285). 
 
You asked the Plan to pre-approve the implantation of a replacement LOOP recorder. You say that this is still 
needed. The Plan denied your request. The Plan says no arrhythmia has been identified on the loop recorder 
since it was originally implanted in 2018. 
 
The Plan follows Medicare rules. Medicare rules say that an Implantable (or Insertable Loop) Recorder (ILR) is 
implanted subcutaneously in a patients upper left chest and may remain implanted for many months. An ILR 
is covered when syncope is thought to be cardiac-related, but is too infrequent to be detected by either a Holter 
monitor or a traditional pre-symptom Memory Loop Recorder (MLR).  
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 implantation of a replacement 
LOOP recorder. Our reviewer says that there is insufficient clinical evidence to support the medical 
appropriateness and necessity of replacing the device. Our physician reviewer found the device had been 
placed to search for significant arrhythmias, which have never been observed over the life of the device. 
 
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 implantation of a replacement LOOP recorder have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the implantation of a replacement LOOP recorder 
(33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically necessary. The Plan denied your 
request. The Plan says IGRT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IGRT. Our reviewer says that IGRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found IGRT is a means 
to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize 
normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning 
target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to 
radiation. For radiation in the palliative setting, IGRT could be considered medically necessary when it is 
necessary to escalate the dose (i.e., oligometastases), particularly when using very high dose per fraction, or 
when critical normal tissues abutting the target necessitate daily image guidance to allow minimal planning 
margins to spare the normal tissue. For the palliative treatment of bone metastases, the use of IGRT is generally 
considered not medically necessary outside of a medically plausible rationale (i.e., prior radiation treatment, unusual anatomy). In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would 
afford. It seems as though IGRT is simply being used as routine practice, as there does not seem to be any 
exceptional circumstances with this enrollee necessitating the need for IGRT. The records include only, for 
justification of IGRT, a checkbox template form that does not provide a plausible reason for why IGRT would 
be needed outside of it being given for routine care. IGRT is not an accepted standard of care for routine use in 
the palliative treatment of bone metastases.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGRT.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab and Ipilimumab. 
 
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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 not medically necessary. Our physician reviewer found the enrollee has metastatic ALK4-
positive adenocarcinoma of the lung. The Food and Drug Administration (FDA) has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The services 
are 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 Nivolumab and Ipilimumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve the requested item. You say that you are unable to get out of your chair 
easily. The Plan denied your request. The Plan says the equipment is not covered. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a standard recliner with a power lift assist and massager was requested. Although a seat lift 
chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items 
that Medicare covers. The item at issue in this appeal does not serve a purpose that is primarily medical in 
nature. This item is available to the general public and would be helpful even to those who are not sick or 
injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 4 additional PT visits. You say that you require PT at least two to three 
times per week. You say that without therapy, you lose range of motion. You say that you are not able to 
perform the exercises on your own because your muscles only developed up to 30%. You also say that you 
have extremely limited find and gross motor skills, which affect doing the home exercise program. The Plan 
denied your request. The Plan says that 4 additional PT visits are not medically necessary. The Plan also says 
the intensity of the requested service is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional PT visits. Our reviewer 
says that the requested 4 additional PT visits are medically necessary. Our physician reviewer found the 
provided documentation indicates that you have complex functional and mobility impairments. The reviewer 
found that you are wheelchair bound with contractures. The reviewer also found that you have not met all the 
appropriate goals. Therefore, the reviewer found that the requested 4 additional physical therapy visits are 
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 4 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve 4 additional physical therapy (PT) visits.  
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller upgrade, harness for upgrade to 
expandable controller, and electronic connection between wheelchair controller and two or more power seating 
system motors. 
 
You asked the Plan to pre-approve expandable controller upgrade, harness for upgrade to expandable 
controller, and electronic connection between wheelchair controller and two or more power seating system 
motors. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has bilateral upper limb 
strength of two to three out of five. The enrollee is independent for eating. The enrollee's upper limb strength 
and function are therefore adequate for the enrollee to be able to control the power options using their own 
switches which are included in the allowance of these power options. Based on this information, we decided 
that Medicare rules for coverage of expandable controller upgrade, harness for upgrade to expandable 
controller, and electronic connection between wheelchair controller and two or more power seating system 
motors have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable 
controller upgrade, harness for upgrade to expandable controller, and electronic connection between wheelchair 
controller and two or more power seating system motors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 
13, 2021. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the attached documents should 
be reconsidered, and the claim reprocessed for payment. The Plan denied your request. The Plan says 
procedure codes 36561, 77001, 76937 and 99152 were already paid. The Plan also says CPT code 99153 may 
not be paid if furnished to hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99153 have not been met. 
Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on 
December 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 25, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office consultation 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 services are necessary. The 
Plan denied your request. The Plan says there is an in-network provider that can perform the services you need. 
The Plan states they approved a follow-up visit with a network provider. 
 
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 consultation to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing provided on February 10, 2022. 
 
You asked the Plan to pay for F1CDx testing. 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 non-covered. Since this panel includes that, the 
denial is correct. 
 
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 solid tumors. No other valid denial rationale was 
presented by the Plan. Therefore, we decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing 
provided on February 10, 2022.  
 
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 the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence-based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. There were no formal MRI or CT imaging studies provided to corroborate the level of spinal 
stenosis of the lumbar spine, including at the level requested of L3-4. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical 
records. The height is 5 feet 8 inches, weight is 290 pounds, and body mass index is 44.09 kg/m2. There is no 
discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the request for Vertiflex Superion interspinous device at L3-4 is 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary interim partial denture (D5820). 
 
You asked the Plan to pre-approve a partial denture. You say that this service should be covered for senior 
citizens. The Plan denied your request. The Plan says a maxillary interim partial denture (D5820) is not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary interim partial denture (D5820).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve ultrasound elastography of liver (76981). 
 
You asked the Plan to pre-approve the ultrasound. You say that the service should be approved. The Plan 
denied your request. The Plan says that the requested ultrasound 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 the ultrasound. Our reviewer says that 
the requested ultrasound is considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that the enrollee's diagnosis qualifies them for the requested 
service. Therefore, the reviewer found that the requested service 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 the ultrasound have been met. Therefore, we decided that the Plan has to pre-
approve ultrasound elastography of liver (76981).  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing on behalf of the 
enrollee, the denial of LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient 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 the enrollee was admitted to the acute care hospital with acute respiratory failure 
from COVID-19 pneumonia requiring oxygen supplementation, antibiotics, and steroids. Recent notes describe 
the enrollee as still dependent on high flow oxygen via nasal cannula, with hypotension, and intermittent 
confusion. The enrollee appears to be somewhat unstable and should require only short-term additional acute 
care services that can be safely 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 facility where 
they are 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 the LTACH services.