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

 
We decided that the Plan does not have to pay for lab services (85018, 84155, 84165, 84100, 80048, 0077U, 
83521, 82652, 83970, 82306) provided on June 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation did not support the billed services. 
 
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 lab services have been met. The 
documentation submitted to support the claim and the initial appeal did not include a physician order or 
medical records documenting clear intent for the billed lab tests to be performed. The plan requested additional 
information and it was not provided. Therefore, we decided that the Plan does not have to pay for lab services 
(85018, 84155, 84165, 84100, 80048, 0077U, 83521, 82652, 83970, 82306) provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has had recurrent 
hospitalizations for heart failure. The Plan denied your request. The Plan says the service is considered 
investigational.  
 
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. 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve a home health aide. 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 custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home health aide have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home 
health aide.
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 the LTACH is not medically necessary.  
The Plan denied your request. The Plan says  the LTACH services are not medically necessary, and the 
enrollee's needs are being met in the current hospital location.  
 
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 acute hospital can provide for all the enrollee's present inpatient care needs and 
the patient is receiving an appropriate level of care in the present setting. The provided records do not explain 
what care services will be provided in the LTACH that are not available in the present hospital setting.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Check test strips. 
 
You asked the Plan to pre-approve Accu-Check test strips. You say that the items are necessary. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-Check test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Check test 
strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary for this patient. The Plan 
denied your request. The Plan says there is no good evidence showing that SBRT is the appropriate course for 
the patient's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The patient was seen in consultation and a course of palliative radiotherapy to the bulk of the 
tumor was recommended for local control hoping to reduce the risk of esophageal obstruction, post obstructive 
pneumonia, pain, and bleeding. A plan for SBRT to a total dose of 30Gy in 5 fractions was recommended. Considering the treatment intent (palliation and local control), there is no evidence that using the SBRT 
technique can provide superior outcomes in this patient. Other techniques like 3D conformal radiation or 2D 
technique are safe and effective in this case. If the goal is to limit the number of treatment visits, other dose 
fractionation (e.g., 20Gy  25Gy in 5 fractions) and other techniques (like 3D technique) can be considered and 
are known to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiotherapy (SBRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says there is no documentation of syncope or 
cryptogenic stroke. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent 
indication for an ILR. 
 
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 ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 You asked the Plan to pre-approve a CPAP device. You say that the item should be covered. The Plan denied 
your request. The Plan says you failed the initial 12-week trial as your 30-day compliance was never a 
minimum of 4 hours per a 30-day period. 
 
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP 
greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime 
during the first three (3) months of initial usage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman interspinous device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatments. 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 Minuteman device is experimental in spinal surgery. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiotherapy. 
 
You asked the Plan to pre-approve the requested services. You say that proton therapy has demonstrated 
improvement in overall survival. The Plan denied your request. The Plan says the coverage criteria have not 
been met.  
 
The Plan follows Medicare rules. Medicare rules say that proton beam radiotherapy is only covered under 
certain medical indications. 
 
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 a plan comparison is not provided, and it is not plausible that a proton plan would reduce 
normal tissue exposure, relative to a well-designed IMRT plan, in a clinically meaningful way that would be 
relevant and applicable to those with poor life expectancy. Proton therapy will invariably reduce normal tissue 
exposure, but not always in a clinically meaningful way. This is particularly relevant for those with 
leptomeningeal disease which carries a very poor prognosis such that late complications of radiotherapy are 
generally not clinically relevant. For craniospinal radiation with leptomeningeal disease, a well-designed IMRT 
plan, prioritizing sparing of organs at risk, can be considered medically necessary over a standard 3D plan, as 
the 3D plan is inadequate in sparing bowel, lung, heart, and esophagus. However, there is no accepted benefit 
of proton therapy over IMRT. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 sensor.  
You asked the Plan to pre-approve a Freestyle Libre Kit 2 sensor. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre Kit 2 sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre Kit 2 sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab (Opdivo). 
 
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says there is no clinical 
support for the continuation of nivolumab in biopsy proven progression of esophageal cancer.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Opdivo. Our physician reviewer found 
that the enrollee has a diagnosis of moderately differentiated adenocarcinoma of the gastroesophageal 
carcinoma. The record indicates that the enrollee has had progression of disease while on the requested drug. 
The FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. Therefore, the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve nivolumab (Opdivo).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization (GAE). 
 
You asked the Plan to pre-approve the requested services. You say that the minimally invasive therapy reduces 
mortality and morbidity compared to other options. The Plan denied your request. The Plan says there is little 
evidence that this is an appropriate product for knee arthritis. 
 
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 genicular artery embolization is experimental for knee pain. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular artery embolization (GAE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
and accessories. 
 
You asked the Plan to pre-approve the CPAP device and related accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says you have not demonstrated at least 70% compliance within 30 days over the first 3 months of use, and your records to do not show you had provider 
face-to-face visit documenting that symptoms have improved. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP device and related accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuous positive airway pressure (CPAP) device and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing admission. 
 
You asked the Plan to pre-approve a skilled nursing admission. You say that the enrollee has been cleared for 
discharge and medically cleared. You also say that it is unsafe to discharge the enrollee home or to an assisted 
living facility, and they require skilled nursing and rehabilitation. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on October 1, 2023. The services in question have been 
requested before the end of that month. Therefore, we decided that the Plan does not have to pre-approve a 
skilled nursing admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tracheostomy, inner cannula (A4623), moisture 
exchanger (A4483), and tracheostomy speaking valve (L8501) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve tracheostomy, inner cannula, moisture exchanger, and tracheostomy 
speaking valve. You say that the services are necessary. The Plan denied your request. The Plan says there are 
in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
tracheostomy, inner cannula (A4623), moisture exchanger (A4483), and tracheostomy speaking valve (L8501) 
to be provided by an out-of-network (OON) provider.
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 enrollee lives alone and is in a weakened 
condition. You say that the enrollee would benefit from sub-acute rehabilitation before returning home.  The 
Plan denied your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can 
be met in a lower level of care such as a long-term care facility.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does 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.