Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combined right and left heart catheterization, 
 
You asked the Plan to pre-approve combined right and left heart catheterization. You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says combined right and left heart 
catheterization is not medically necessary. The medical records do not show suspicion for coronary artery 
disease, structural cardiac abnormalities, or pulmonary hypertension. The notes do not show the results of your 
work up for cardiac amyloidosis or the need for a cardiac biopsy. 
 
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 combined right and left heart 
catheterization. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the record indicates that you have dyspnea on exertion and tachycardia in the setting of a previous pulmonary embolus.  The record does not indicate the 
presence of any chest pain or abnormal stress test.  The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules,  of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of combined right and left heart catheterization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve combined right and left heart catheterization,
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic endplate changes 
without facet degenerative joint disease (djd) or foraminal stenosis. The cause of the back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
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 reasonable and necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented, ongoing, home health physical therapy needs. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7.  
You asked the Plan to pre-approve a Dexcom G7. 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. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G7.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH level of 
care and is medically stable for discharge. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee's needs can be met in another setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensors.  
You asked the Plan to pre-approve the Freestyle Libre 2 sensors. You say that the medical records support the 
medical necessity for the CGM. The Plan denied your request. The Plan says the record from your provider 
indicates that you do not meet any criteria for coverage of the FreeStyle Libre 2 sensors. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre 2 sensors. Our 
reviewer says that the elements of coverage criteria are not satisfied. Our physician reviewer found the record 
indicates you have diabetes. The record provided does not indicate that you are being treated with insulin or 
have problematic hypoglycemia as defined by Medicare rules. 
 
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 Freestyle Libre 2 sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Libre 2 sensors.
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 you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
skilled nursing facility services.  
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, 
provided records do not document a significant decline in the enrollee's functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. Records support that services in the home with 
home health care or in a long-term care facility on a part time basis are appropriate 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not require 
intensive care management or at high risk of hospitalization. Therefore, we decided that the Plan does not have 
to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are appealing the denial because you 
need the scooter to go out to the post office and for grocery shopping. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare criteria for the requested power scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair and you cannot 
safely operate the PMD being requested. The records indicate that you stated you have no need for any mobility devices inside your home and that your apartment is very small, and you could not accommodate a 
mobility device inside your home. A power operate vehicle is only covered for use inside the home and your 
home is able to accommodate it. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that stereotactic body radiotherapy was the chosen method 
of treatment for this patient's multiple myeloma involving a sacral tumor in order to achieve accuracy and 
precision in the dosage delivery to the planned target area while protecting the surrounding critical structures of 
the cauda eguina and small bowel. Due to the location of the tumor volume being near critical structures, it is 
imperative that these surrounding critical structures be spared as much as possible while providing adequate 
radiation to the tumor area. The Plan denied your request. The Plan says stereotactic body radiotherapy is not 
medically necessary for the patient's bone marrow cancer. Other treatments are more proven and effective for 
the patient's condition. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT, delivering high fractional doses in 3-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. For metastatic disease, SBRT is generally indicated for patients with 
oligometastatic disease of for those undergoing palliation after prior radiation to the same site. 
 
The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting 
national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically 
necessary when the patients performance status justifies aggressive treatment, and for those whose tumor 
burden can be completely targeted with acceptable risks- which does not apply for multiple myeloma. The 
International Lymphoma Radiation Oncology Group do not describe SBRT being indicated for any clinical 
situation for multiple myeloma. Generally the doses to treat multiple myeloma are low such that the dose 
escalation afforded by SBRT is not necessary. 
 
Based on ASTRO model policy, routine use of SBRT for palliation of spine metastases in the setting of more 
widespread disease (as is the case with multiple myeloma) is not in accordance with accepted standards of 
medical practice. While it is reasonable to offer this patient palliative radiotherapy with standard 2D palliative 
regimens, there is not an evidenced based rationale for SBRT in this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiotherapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift (E2300). 
 
You asked the Plan to pre-approve a seat lift. You say that you feel your daughter needs this item for everyday 
needs. The Plan denied your request. The Plan says the requested items is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not covered. 
 
We looked at the file and Medicare rules. The requested item is specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of a seat lift have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a seat lift (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0825). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair. You say that you cannot use a 
manual chair because you are too heavy for anyone to push you, and you are not strong enough to push it 
yourself. You also say that if you had a power wheelchair you could go shopping and get out of the house and 
do things. The Plan denied your request. The Plan says the information received does not meet criteria because 
it did not indicate that you are unable to safely perform your usual home activities with the use of a cane, 
walker, manual wheelchair, or motorized scooter. The Plan also says that there is no documentation indicating 
that your home provides adequate access and space to get around.  
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say that the beneficiary's medical records will reflect 
the need for the care provided. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. The provided documentation also does not 
include a home evaluation. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy 
duty power wheelchair with a patient weight capacity 301 to 450 pounds (K0825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary 
and other devices have been ruled out. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary. The patient's needs can be met with a bilevel positive airway pressure (BiPAP) device 
with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of 
such a device has not been documented.   
 
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 6, 
2021, to October 27, 2021, at the original rate code billed. 
 
You asked the Plan to pay for SNF care at the original rate billed.. You say that these services were necessary 
and were reported appropriately. The Plan denied your request. The Plan says there is insufficient information 
to support the rate code submitted for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SNF care at the original rate billed. 
have been met. Specifically, the records are missing necessary documentation to support the rate code billed for 
the dates of service in this case. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) care provided from October 6, 2021, to October 27, 2021, at the original rate code billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the member is receiving medically necessary acute 
and/or critical care. The member does not have clinical conditions that cannot be appropriately treated in the 
current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
 
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 medical records do not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are not satisfied.  The requested service cannot be recommended. 
 
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 LTACH services.