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

 
We decided that the Plan does not have to pre-approve an upper lid blepharoplasty. 
 
You asked the Plan to pre-approve a blepharoplasty. You say that your vision is in danger. The Plan denied 
your request. The Plan says the medical criteria for a blepharoplasty 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 a blepharoplasty. 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 documentation of marginal reflex distance (MRD) of less than 2mm. The 
photos provided are dark/not interpretable and do not clearly demonstrate that the eyelid skin is overhanging 
into the visual axis. 
 
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 blepharoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upper lid blepharoplasty.
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 LTACH care would be the best option 
for the enrollee to receive the best care and prevent readmission to the hospital. 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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95806 billed for date of service September 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the service is included in payment for inpatient services. 
 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 95806 is sleep study, unattended, simultaneous recording 
of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort. We find that CPT code 95806 was 
billed within 3 days and related to the enrollees inpatient care. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 95806 billed for date of service September 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were  admitted for a 
urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While the medical records support a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the submitted medical records support 
the need for LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, 
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 is receiving appropriate care in the current acute case setting as provided 
by the health plan. The documentation does not support that LTACH services are medically appropriate at this 
time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested 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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device was 
approved by the FDA in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 120 units of ostomy pouches (A5063) over 
a 6-month period. 
 
You asked the Plan to pre-approve ostomy supplies. You say that the enrollee needs these supplies. The Plan 
denied your request. The Plan says the record does not show why this quantity beyond the usual limit is 
needed. 
 
The Plan follows Medicare rules. Medicare rules state that the explanation for use of a greater than usual 
quantity of ostomy supplies must be clearly documented. 
 
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 ostomy supplies. Our reviewer says that 
the enrollee does not meet criteria for the requested additional quantity of ostomy supplies. Our physician 
reviewer found documentation does not clearly justify why the enrollee needs supplies beyond what is 
normally covered for ostomy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ostomy supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional 120 units of ostomy pouches (A5063) over a 6-month period.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Glucocard shine strip. 
 
You asked the Plan to pre-approve Glucocard shine strip. You say that you do not agree with the denial for the 
requested items. The Plan denied your request. The Plan says that the request is for a non-preferred blood 
glucose test strip; therefore, the request cannot be authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has no preferred brand of diabetic supplies and havent given any other 
reason to support the denial. The Evidence of Coverage (EOC), on pages 53-54 states supplies to monitor your 
blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control 
solutions for checking the accuracy of test strips and monitors. The EOC does not list preferred products. 
Therefore, we decided that the Plan has to pre-approve Glucocard shine strip.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro arm brace. You say that the MyoPro can be supplied only by a 
small group of highly skilled clinicians who have been trained and certified to fit this orthosis. Therefore, 
Myomo, Inc., needs to supply the orthosis directly to the enrollee at an in-network level, as other 
orthotic/prosthetic providers have not been trained. The Plan denied your request. The Plan says experimental 
and investigational procedures are not covered by Medicare. 
 
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 a MyoPro arm brace. 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 medical records provided there is no documentation that the MyoPro 
arm brace at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
enrollee. Current clinical guidelines for adult stroke rehabilitation and recovery designate robotic therapy to be 
of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment. Although records from the device manufacturer/vendor argue medical 
necessity of the requested device, records from the enrollees actual treating provider do not clarify why the 
requested device is the most appropriate treatment for the enrollees condition. 
 
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 MyoPro arm brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro arm brace (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this enrollee had progression of disease 
while on pembrolizumab. Retreatment after progression is not FDA approved or supported by the literature. 
The service was 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing coded as 81479, 81225, 81226, 
81227, 81231, 81240, 81241, 81291 and 81328. 
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says based on the Medicare guidelines the 
request for pharmacogenomic testing 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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the testing assesses the presence of pathogenic or likely pathogenic variants in genes 
known to be associated with increased cardiovascular risk. It is not a diagnostic test. There is no evidence to 
support its role in this patient clinical management. In summary, the requested testing is not considered 
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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the genetic testing coded as 81479, 81225, 81226, 81227, 81231, 81240, 81241, 81291 
and 81328.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical notes did not contain any information about the lung nodule. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has been undergoing surveillance for a solitary pulmonary nodule.  The record 
provided is insufficient to establish the medical necessity of the requested service at this time. The elements of 
the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation. 
 
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 genicular nerve ablation is 
the subject of ongoing clinical trials to establish what role they play in the treatment of knee osteoarthritis. The 
procedure is considered experimental and not medically necessary at this time. 
 
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 genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Baxter NanoBone allograft (20930 x 2). 
 
You asked the Plan to pre-approve the Baxter NanoBone allograft. You say that the enrollee is in a lot of pain. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational for 
use in fusion procedures. 
 
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 Baxter NanoBone allograft. Our 
reviewer says that the requested Baxter NanoBone allograft is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted 
pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the reviewer found that the requested 
Baxter NanoBone allograft is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Baxter NanoBone allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Baxter NanoBone allograft (20930 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Laparoscopic Esophageal Sphincter Augmentation 
(LINX procedure) (43284).  
 
You asked the Plan to pre-approve the LINX procedure. You say that this procedure is no longer experimental.  
The Plan denied your request. The Plan says this type of surgery is considered experimental and/or unproven.  
 
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 LINX procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case, the record indicates that the enrollee has diaphragmatic hernia 
without obstruction or gangrene and g gastroesophageal reflux disease (GERD) without esophagitis. There is 
insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. The elements of the coverage criteria are not satisfied.  
 
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 LINX procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Laparoscopic Esophageal Sphincter Augmentation (LINX procedure) (43284).