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

 
We decided that the Plan does not have to pre-approve Surface Guided Radiation Therapy (SGRT) 
(VisionRT/AlignRT). 
 
You asked the Plan to pre-approve SGRT (VisionRT/AlignRT). You say that the SGRT is medically necessary. 
The Plan denied your request. The Plan says the requested service is not covered by Medicare or the health 
Plan. 
 
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 SGRT (VisionRT/AlignRT). Our 
reviewer says that the requested SGRT (VisionRT/AlignRT) is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that ideally, breath-hold techniques should be used for 
radiation treatment of left breast cancer to decrease the dose of radiation to the heart. While the utilization of SGRT can potentially improve the accuracy of radiation treatment and delivery, it is still not considered a 
standard of care for radiation treatment of left breast cancer patients. SGRT is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SGRT (VisionRT/AlignRT) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Surface Guided Radiation Therapy (SGRT) (VisionRT/AlignRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to approve Synvisc One.  
 
You asked the Plan to approve Synvisc One. You say that you want to try this injection to see if it will relieve 
some of your discomfort. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Synvisc One in the setting of hip osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to approve Synvisc One. Our reviewer says that the 
criteria for coverage have not been met. Our reviewer found that you have osteoarthritis of the left hip. This is 
an off-label use of this medication and is not evidence based. Therefore, the request is deemed not 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 Synvisc One  have not been met. Therefore, we decided that the Plan does not 
have to approve Synvisc One.
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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval have not been met. 
 
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 that the enrollee is functioning at a home care level. On August 18, 2023, the enrollee 
was able to walk, transfer, toilet, and perform self-care with a supervision level of function. Daily skilled 
therapy services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional home physical therapy visits. 
 You asked the Plan to pre-approve nine (9) additional home physical therapy visits. You say that the additional 
physical therapy visits are medically necessary. The Plan denied your request. The Plan says the additional 
physical therapy visits 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 nine (9) additional home physical 
therapy visits. Our reviewer says that the additional home physical therapy visits are not medically reasonable 
and necessary. Our physician reviewer found the clinical documentation shows that the enrollee has met all 
home health physical therapy goals thus the records do not show that additional physical therapy sessions 
would be required in home setting to effectively provide treatment, care, and/or services in order to improve the 
enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of 
function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nine (9) additional home physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve nine (9) additional home physical therapy visits.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ultomiris. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee's life, health, or ability to regain 
maximum function is in serious jeopardy if the determinations is not made in the standard time frame. The Plan 
denied your request. The Plan says that Ultomiris is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Ultomiris is medically necessary. Our physician reviewer found that the requested use of Ultomiris is FDA- 
approved. Ultomiris is also safe and effective and otherwise reasonable and necessary for the 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Ultomiris.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) 
services.  
 
You asked the Plan to pre-approve IMRT services. You say that IMRT is medically necessary to reduce 
toxicity and avoid overlap with nearby organs at risk, including the small bowel and spinal cord.  The Plan 
denied your request. The Plan says the requested IMRT 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 IMRT services. Our reviewer says that 
the requested IMRT services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no published data on the use of 10 fraction IMRT palliation of gastroesophageal 
junction adenocarcinoma disease.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Intensity Modulated Radiation Therapy (IMRT) 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. You say that the enrollee requires intensive therapy services to 
return to independence. The Plan denied your request. The Plan says the enrollee does not meet the 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 electronic connection (E2311).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that when two power 
seating functions/actuators/motors are provided, one unit of E2311 is allowed.  The Plan denied your request. 
The Plan says an electronic connection cannot be covered as it is not medically necessary to control the two 
power options through the joystick (drive interface).  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  an electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services.  
 
You asked the Plan to pre-approve PBRT services. You say that the requested radiation therapy is needed 
urgently for growing cancer.  The Plan denied your request. The Plan says PBRT is not the standard of care for 
prostate cancer and is not considered reasonable and 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 PBRT services. Our reviewer says that 
the requested PBRT services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the difference between proton and photon irradiation is that the protons (or charged particles) 
stop abruptly in the tissue so there is less exit dose through normal tissue. It is noteworthy that the depth of 
proton delivery is more susceptible to changes in tissue density (such as changes of air in the rectum). Generally, proton beam arrangements are designed so as to not enter through the rectum. Given these issues, 
there is also the possibility that proton therapy is disadvantageous. Presumably this patient is being offered 
pelvic radiotherapy as he had had a prostatectomy in the past, though he also has a rib metastasis such that the 
need to treat the pelvis is dubious, and proton therapy would be far outside the scope of standard practice. 
Proton therapy for this patient would NOT be furnished in accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), backpack holder (K0108), deluxe quantum backpack (K0108), and drain bag 
holder for wheelchair (K0108).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the multiple power options (power tilt and power 
recline) are not medically necessary. The Plan also says the backpack holder, deluxe quantum backpack, and 
drain bag holder cannot be covered as they do not serve a medical purpose.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. There is not a medical need for the upgraded electronics, the 
backpack, the backpack holder or the drain bag. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), backpack holder (K0108), deluxe quantum backpack (K0108), and drain bag 
holder for wheelchair (K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306).  
 
You asked the Plan to pre-approve the service. You say that medical records have been provided to support the 
medical necessity of this service.  The Plan denied your request. The Plan says this 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical guidelines do not support carrying out a TTE in this setting. In summary, there is no 
supportive evidence for the medical necessity of a TTE in this this enrollee's 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp.  
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Aranesp is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Aranesp is not medically necessary.  Our physician reviewer found that the enrollee does not meet the criteria 
for Aranesp for anemia of chronic kidney disease based on the documentation provided. Also, the hemoglobin 
is not low enough and there is no indication provided in the notes to justify the use of Aranesp. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IsoPSA testing provided on February 10, 2023.  
 
You asked the Plan to pay for the IsoPSA testing. You say that this testing is covered per Local Coverage 
Determination L39284. The Plan denied your request. The Plan says no medical records were submitted to 
support this service was reasonable and necessary.  
 
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 the IsoPSA testing have been met. This 
claim was originally denied for missing medical records. The appeal request argued that this test was covered 
but did not include records. The Plan documented attempts to request these records, which were not received 
within the time frame allowed. Therefore, we decided that the Plan does not have to pay for the IsoPSA testing 
provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 
cm rendered on February 15, 2023. 
 
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 Current Procedural Terminology (CPT) 13151-59 remains not supported. 
 
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 13151 is "Repair, complex, eyelids, nose, ears and/or 
lips; 1.1 cm to 2.5 cm." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 13151 was performed separately and distinctly from the primary procedure - CPT 69000. This primary 
procedure has inclusions within the code that cover the work being done to close the wound if necessary. 
 
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 repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm rendered on February 15, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).   
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you really need the lift 
on your wheelchair, it would make your life so much easier, and the medical staff that service your medical 
needs.  The Plan denied your request. The Plan says although there are three approved power options on this 
wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options 
through the joystick.  
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested electrical accessories are not medically necessary as you 
do have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for the upgraded electronics. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).