Persius/hicric huggingface dataset:
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 feel the enrollee should be getting physical 
therapy. The Plan denied your request. The Plan says there is no documentation to support the medical 
necessity for skilled services at this time.  
 
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 have identifiable skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse; however, the enrollee does not require skilled 
nursing services on a daily basis. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 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: 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 due to the enrollee needing ongoing medical 
management and intensive therapy, they are not safe to directly return home at their current level of function. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an IRF.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inspire hypoglossal nerve stimulator. 
 
You asked the Plan to pre-approve an Inspire hypoglossal nerve stimulator. You say that a sleep study was 
already completed and this device is needed.  The Plan denied your request. The Plan says the notes do not show you have a sleep study performed within 
24 months of first consultation for hypoglossal nerve stimulator implant. The notes also do not show that you 
meet the other criteria for coverage.  
 
The Plan follows Medicare rules. Medicare rules say that a polysomnography (PSG) is performed within 24 
months of first consultation for HGNS implant. 
 
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 Inspire hypoglossal nerve stimulator. 
Our reviewer says that this device is not medically necessary. Our physician reviewer found that in this case, 
there is no documented sleep study in past 24 months. The review has determined that the coverage criteria 
have not been met. 
 
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 Inspire hypoglossal nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Inspire hypoglossal nerve stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not suggest a 
history of unexplained stroke or any other apparent indication for an ILR. The services are not reasonable or 
medically necessary for the your clinical management. 
 
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 insertion of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for image-guided radiation therapy 
(IGRT). 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of ultrasound on a daily basis is 
approved by the Food and Drug Administration (FDA) but that in and of itself does not mean that daily 
imaging is necessary, but simply that the device was designed to incorporate this functionality. The services 
have not been established by published data or supported by consensus guidelines. The services are not the standard of care and are 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 ultrasonic guidance for image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair and accessories ( E0954,E0956, 
E0971, E0973, E0990, E1028, E1161, E2202, E2204, E2208, E2231, E2609, E2617, K0040, K0108, E2617). 
 
You asked the Plan to pre-approve the manual wheelchair and accessories. You say that this item is medically 
necessary. The Plan denied your request. The Plan says the enrollee resides in a skilled nursing facility. 
Medicare does not cover medical equipment for use in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the manual wheelchair and accessories is being requested for use in a SNF or hospital.  
Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories ( 
E0954,E0956, E0971, E0973, E0990, E1028, E1161, E2202, E2204, E2208, E2231, E2609, E2617, K0040, 
K0108, E2617).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says  the 
clinical effectiveness has not been demonstrated.  
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). Published expert opinion in the 
cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this enrollees clinical management. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection of sclerosant; multiple incompetent veins 
(other than telangiectasia), same leg (36471). 
 
You asked the Plan to pre-approve the varicose veins treatment. You say that you are appealing the denial as 
the services were medically necessary. The Plan denied your request. The Plan says the information provided 
does not reveal any conditions to support medical necessity. 
 
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 varicose veins treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the procedures 
in question. The enrollee has already undergone extensive endovascular treatments of the lower extremities 
bilaterally. The description of current symptoms is nonspecific and lacks sufficient detail from which to assess 
medical necessity. Additionally, the enrollees primary care physician notes no symptoms related to varicose 
veins and, in fact, is concerned there may be a component of peripheral arterial disease severe enough to 
warrant the ordering of arterial testing. The results of this have not been provided. In the absence of a clear 
description of symptom findings including an assessment as to why the numerous endovascular procedures 
including no less than 6 ablations of the legs have failed to alleviate the enrollees symptoms in either leg 
combined with the concern of the enrollees primary care physician regarding possible peripheral artery 
disease, unable to overturn the health plan determination on the basis of medical necessity. 
 
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 varicose veins treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the injection of sclerosant; multiple incompetent veins (other than 
telangiectasia), same leg (36471).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes N26.9 and 
N05.8. Diagnosis code N26.9 has an Excludes1 note, and cannot be billed with diagnosis code N05.8. 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 the services provided on January 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had good results with this 
medication. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 You asked the Plan to pre-approve home health care. You say that you are appealing this 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 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 care. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the documentation 
does not support that you require additional skilled rehabilitation services to provide medically necessary 
treatment or perform a maintenance program to maintain your condition and/or prevent deterioration. You have 
been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
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 you are requesting an expedited 
reconsideration stating the enrollee clearly exceeds the criteria for a medically appropriate LTACH admission. 
The Plan denied your request. The Plan says the request for coverage for admission to an LTACH is being 
denied as not medically necessary.  
 
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 to be unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for transfer. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous and completion of treatment at the current facility is 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 continuous glucose monitor. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
medically necessary criteria.  
 
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. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the limited documentation provided, the health Plans denial should be 
upheld. The enrollee is noted to have diabetes. How often the enrollee monitors their blood sugar is unclear. 
There is no evidence that the enrollee uses insulin and needs to adjust their insulin multiple times per day.  As 
such, the requested CGM is not shown to be medically necessary, reasonable or coverable. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Freestyle Libre 2 continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for the procedure.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
under certain medical imaging. 
 
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 requested services. Our physician 
reviewer found that there is no documentation of an adequate trial of bracing. The coverage criteria have not 
been met. Therefore, the request is not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial foot prosthesis (L5000). 
 
You asked the Plan to pre-approve the partial foot prosthesis. You say that this item is medically necessary. 
The Plan denied your request. The Plan says the documentation provided does not support the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to justify payment for durable medical 
equipment (DME) items, suppliers must provide a standard written order. 
 
We looked at the file and Medicare rules. The code requested is not included on the standard written order 
submitted. Based on this information, we decided that Medicare rules for coverage of the partial foot prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial foot prosthesis 
(L5000).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) 
procedure (0275T). 
 
You asked the Plan to pre-approve a MILD procedure. You say that the requested service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered when provided in a clinical 
study through CED for beneficiaries with LSS who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a MILD procedure have not been met. Specifically, the case record does not support that the 
enrollee is participating in an approved clinical study. Therefore, we decided that the Plan does not have to pre-
approve a minimally invasive lumbar decompression (MILD) procedure (0275T).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provide on December 4, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. The record shows that the claim was billed with diagnosis code 
F06.8. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Based on this information, we decided that Medicare rules for coverage of the services have 
been met. Therefore, we decided that the Plan does not have to pay for the services provide on December 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. In this case, the claim was billed with diagnosis codes R09.02 and 
J96.01. Diagnosis code R09.02 has an Excludes1 note and is not payable when billed with diagnosis code 
J96.01. 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 the services provided on December 23, 2022.