Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request is not medically necessary because records show that the 
ordered settings for the noninvasive ventilator can be delivered by a bi-level PAP machine with AVAPS 
capability. The records do not show the enrollee failed to improve with BiPAP. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with a 
recent exacerbation, with pneumonia, requiring hospitalization. ABG was consistent with acute on chronic 
hypoxic and hypercarbic respiratory failure. The enrollee improved with bipap in the hospital. There is no ABG 
done while stable to document chronic CO2 retention. If that is present, the enrollee may benefit from BiPAP 
with AVAPS during sleep. This has not been tried and shown to fail as an outpatient.  Medicare does not cover 
a home ventilator when used 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that this provider has treated you for a number of 
years. The Plan denied your request. The Plan says there are in-network specialists available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve pain 
management services to be provided by an out-of-network (OON) provider.
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 item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this Respiratory Assist 
Devices (RAD) policy will be denied as not 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 a portable ventilator. Our reviewer says that the enrollee does not need this item. Our physician reviewer found provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided 
medical records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart System (heart contractility 
modulation system) (code 0408T). 
 
 
You asked the Plan to pre-approve the Optimizer Smart System (heart contractility modulation system). You 
say that the Optimizer Smart System (heart contractility modulation system) is medically necessary. The Plan 
denied your request. The Plan says the Optimizer Smart System (heart contractility modulation system) is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Optimizer Smart System  
(heart contractility modulation system). Our reviewer says that the requested Optimizer Smart System 
(heart contractility modulation system) is not considered medically reasonable and necessary. Our physician 
reviewer found that an exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity. While the clinical studies led to the Food and Drug Administration (FDA) approval in 2019, CCM 
remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, 
double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is 
premature to presume clinical outcomes and benefit. At the current time, I would not consider the CCM system 
to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Optimizer Smart System (heart contractility modulation system)  
(code 0408T) have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Optimizer Smart System (heart contractility modulation system) (code 0408T).
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 is ready for discharge to the 
LTACH. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
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 the enrollee was admitted with colonic perforation in the setting of ischemic 
bowel and required operative intervention. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH 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: 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. The Plan denied your request. The Plan says your records do not 
show you meet the IRF 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Transcranial Magnetic Stimulation (TMS) 
maintenance treatments. 
 
You asked the Plan to pre-approve the TMS maintenance treatments. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that maintenance therapy is not currently supported 
by evidence from clinical trials and therefore, is considered not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TMS maintenance treatments have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Transcranial Magnetic Stimulation (TMS) maintenance treatments.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) gene analysis, p.Val617Phe 
(V617F) variantJAK2 V617F genotyping. 
 
You asked the Plan to pre-approve the requested services. You say that the testing is needed to rule out 
polycythemia vera. The Plan denied your request. The Plan says the requirements for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the enrollee has not had prior BCR-ABL 
testing. Based on this information, we decided that Medicare rules for coverage of the requested services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) gene 
analysis, p.Val617Phe (V617F) variantJAK2 V617F genotyping.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the left shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that during the encounter on March 24, 2023, 
no red flags were noted, and no provocative maneuvers were done of the left shoulder. The left shoulder x-ray 
report is not in the chart, but the notes say no acute findings were present. No conservative therapy including 
six weeks of physical therapy has been done to justify medical necessity of the requested MRI of the left 
shoulder. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the left shoulder.
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 services are medically necessary. The 
Plan denied your request. The Plan says the LTACH services requested do not meet the 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 the enrollee was admitted with septic shock in the setting of 
small bowel obstruction and intestinal ischemia and required operative intervention. The medical record does 
not indicate that the enrollee requires services that they are not currently receiving but that would be available 
at the LTACH 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Neulasta. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee was admitted to an acute care hospital for dexamethasone, cyclophosphamide, etoposide and 
cisplatin (DCEP) for relapsed, refractory multiple myeloma. The documentation does not support that the 
enrollee has tried and failed Zarxio. The documentation does not support that Zarxio would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Retacrit or Procrit before they will approve the requested drug. The requested drug is a 
new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-
one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Aranesp (J0881).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical procedure codes 20931, 20936, 20937, 20939 
rendered on July 26, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 CPT 20931: 
 
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
 
CPT 20936: 
 
Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar 
fragments) obtained from same incision (List separately in addition to code for primary procedure) 
 
CPT 20937: 
 
Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial 
incision) (List separately in addition to code for primary procedure) 
 
CPT 20939: 
 
Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List 
separately in addition to code for primary procedure) 
 
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 for CPT 20931, 20937, and 20939. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our reviewer found that codes 20931,20936, 
and 20937 are not supported in the medical records. There is no documentation of structural allograft or local 
or iliac crest bone graft with a separate incision. 
 
Additionally, CPT 20936 has a status indicator of B, and cannot be reported separately. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical procedure codes 20931, 20936, 20937, 20939 rendered on July 26, 2022.