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

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring, including deployment & calibration of the 
sensor, rt heart catheterization (33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that you disagree with the denial and 
have provided documentation to support medical necessity. The Plan denied your request. The Plan says 
services that are not medically necessary are not covered under the health benefit plan. The enrollee does not 
meet criteria for approval of this service. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found 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 enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees 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 enrollee management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring, including deployment & calibration of the sensor, rt heart catheterization 
(33289).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Boostrix vaccine. 
 
You asked the Plan to pre-approve a Boostrix vaccine. You say that the enrollee would like to get this injection 
as a preventative. The Plan denied your request. The Plan says this appeal for Boostrix does not meet Medicare 
criteria for coverage under Part B. The Plan also says the request of Boostrix vaccine falls under Part D, and is 
not covered under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Boostrix vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Boostrix vaccine. 
Therefore, we decided that the Plan does not have to pre-approve a Boostrix vaccine.  
 
  Benefits for a Boostrix vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 30, 2022, 
through June 28, 2022.  
 
You asked the Plan to pay for the home health services. You say that this claim should be paid as it was billed 
correctly.  The Plan denied your request. The Plan says the Q-code was not reported for the correct date of 
service.  
 
The Plan must follow Medicare rules. Medicare rules say that for home health claims, the Q-code should be 
reported along with the first visit reported on the claim.  
We looked at the file and Medicare rules. In this case, the Q-code was reported for date of service May 30, 
2022, while the first visit on the claim was for May 31, 2022. Based on this information, we decided that 
Medicare billing rules for the home health services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from May 30, 2022, through June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on October 19, 
2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
17, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on December 7, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has chronic respiratory failure 
and tracheobronchomalacia. She needs the trilogy machine at a minimum 4 hours every day for her quality of 
life. She also has pulmonary fibrosis. Medical records are attached to support medical necessity. The Plan 
denied your request. The Plan says the records do not show that the request for a non-invasive ventilator (NIV) 
to be used exclusively in AVAPS-AE mode is medically necessary since there is no clinical documentation that 
BiPAP has been found to be ineffective for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis, 
interstitial lung disease, tracheobronchomalacia, pulmonary hypertension, and recurrent hospitalizations. 
COPD is occasionally listed as a diagnosis but updated pulmonary function testing results have indicated 
severe restrictive disease with an FVC of 49% of predicted. There is no diagnosis of thoracic restrictive disease 
or neuromuscular disease. There is a listed diagnosis of bronchiectasis, but this is not confirmed on CT scan 
reports. During acute illness, an arterial blood gas on March 24, 2023, showed a normal PaCO2 of 43. There is 
no ABG done while stable to document chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with AVAPS during sleep.  Medicare does not cover a home ventilator in the treatment of interstitial 
lung disease, or when used at settings that can be provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 11, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  Therefore, we decided that 
the Plan does not have to pay for the lab services provided on December 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system . You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is considered experimental. 
 
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 SPRINT PNS system. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the sprint pns system is experimental for hip pain. 
 
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 SPRINT PNS system  have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system (64555).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for hyponatremia. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are unable to get around without an 
electric wheelchair because no one can push you in your current wheelchair. The Plan denied your request. The 
Plan says the reasonable useful lifetime of your current wheelchair is five years old. You do not meet criteria 
for a new wheelchair. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for your current wheelchair on November 10, 2021. and you received 
the wheelchair on February 27, 2022. Your current wheelchair serves the same purpose as a power wheelchair. 
The records also show that there is no evidence that your wheelchair cannot be repaired, and it is less than five 
years old. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0861).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 does not require daily skilled nursing or therapy services. The 
enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64624) provided on February 8, 2023 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for codes 64400, 64405, 64415, 64416, 
64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, 64449, 64454 and 64624 is limited 
to the listed diagnosis codes. 
 
We looked at the file and Medicare rules. Per A57452, diagnosis code M17 is not covered for code 64624. 
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 (64624) provided on February 8, 2023
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bicalutamide tablets (J8999). 
 
You asked the Plan to pre-approve bicalutamide tablets. 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 bicalutamide tablets 
(J8999).  
 
Benefits for bicalutamide tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reduction (19380), revision of reconstructed 
breast (19380), and panniculectomy (18530). 
 
You asked the Plan to pre-approve the breast reduction, revision of reconstructed breast, and panniculectomy . 
You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not 
medically necessary 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast reduction, revision of 
reconstructed breast, and panniculectomy. Our reviewer says that the service is not medically necessary. Our 
reviewer found the case file does not contain sufficient documentation supporting that the enrollee has back, 
neck or shoulder pain from macromastia which is unrelieved by 6 months of conservative analgesia, supportive 
measures, and PT, or has significant arthritic changes in the cervical or upper thoracic spine, optimally 
managed with persistent symptoms and/or significant restriction of activity, or intertriginous maceration or 
infection of the inframammary skin refractory related to dermatologic measures , or permanent shoulder 
grooving with skin irritation by supporting garment. The case file does not contain documentation that the 
pannus or panniculus hangs below the level of the pubis, that the panniculus causes chronic intertrigo that 
consistently recurs or remains refractory to appropriate medical therapy (e.g. topical antifungals, 
corticosteroids, antibiotics) over a period of 3 months.  
 
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 breast reduction, revision of reconstructed breast, and panniculectomy have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the breast reduction (19380), 
revision of reconstructed breast (19380), and panniculectomy (18530).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary. 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 powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. Our reviewer found that there is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee. Our reviewer also found that there is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace.