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

 
We decided that the Plan does not have to pre-approve UV light treatment. 
 
You asked the Plan to pre-approve UV light treatment. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says UV light treatment is not safe due to the nature of 
the enrollee's skin cancer and is contraindicated. 
 
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 UV light treatment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided and review of the current peer-reviewed medical 
literature, there is no documentation that the UV light therapy at issue in this case meets all Medicare criteria 
for medically reasonable and necessary and safe and effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of UV light treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve UV light treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic leg (L5962, L5981, L5986, 
L5988). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a K3 foot is not reasonable and necessary for the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation that supports that the enrollee's  activity subjects his prosthesis to harsh 
environmental situations or that he engages in any extraordinary activities that would justify the need for extra 
protection with a flexible outer surface covering system (L5962). His prosthetic protection can be adequately 
met with the approved L5704 cover.  L5988, L5986 and L5981 are not medically necessary  The 
documentation does not support that the enrollee requires a new K3 foot. The documentation indicates the 
enrollee's current foot is under warranty. Additionally, the physician documentation does not support that the 
enrollee is a K3 ambulator given his comorbidities, history of shortness of breath and chest pain, and use of a 
wheelchair. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement prosthetic leg (L5962, L5981, L5986, L5988).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home. 
 You asked the Plan to pre-approve home health services. You say that you use a walker, and your life and 
health are in danger and need home health services. The Plan denied your request. The Plan says the services 
are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented home health and physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care (i.e., HEP, outpatient therapy, layperson supervision). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagrad. 
 
You asked the Plan to pre-approve Gammagard. You say that this medication is medically necessary. The Plan 
denied your request. The Plan says this medication is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state 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. The 
rules also state that Gammagard is indicated for the specific conditions detailed in the Medicare rules sections. 
 
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 Gammagard. Our reviewer says that the 
noted diagnosis is not one for which coverage is available under the applicable coverage rules. Our physician 
reviewer found neither the Food and Drug Administration or the Medicare approved  major drug compendia support the use of the autonomic neuropathy or idiopathic progressive polyneuropathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagrad.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from January 5, 2023, to 
January 13, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was changed resulting in an 
overpayment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N13.30. 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our physician 
reviewer found that the enrollees hydronephrosis was a chronic condition, which was not treated while 
hospitalized and did not affect the course of the hospitalization. As such, the billing of diagnosis code N13.30 
as a secondary diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from January 5, 2023, to January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis described by code L1851. 
 
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 a knee orthosis is covered when specific criteria 
are met. 
 
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 there is no report of knee pain or instability of the knee examined objectively. The documentation does not reveal plans for knee surgery or 
having had recent surgery or injury. The criteria for coverage are not met and the knee orthosis is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis described by code L1851.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DefineMBC genetic testing (81479). 
 
You asked the Plan to pre-approve DefineMBC genetic testing. You say that these tests are medically 
necessary and appropriate. The Plan denied your request. The Plan says these tests are not approved by the 
FDA as a companion diagnostic test, and therefore is not considered 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 DefineMBC genetic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the required FDA approval or clearance requirement above has not 
been met; therefore, the coverage criteria for genetic testing has not been fulfilled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DefineMBC genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve DefineMBC genetic testing (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2  
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the medical records 
provided support the need for the requested CGM. The Plan denied your request. The Plan says a CGM is not 
covered under Medicare if the enrollee is not on insulin or does not have documentation of recurrent 
problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM. Our physician reviewer 
found coverage criteria for a CGM include low blood glucose sugar (BGS) or insulin use; although this 
enrollee may be at risk for low BGS with an a1c of 5.7 and glipizide use, we are not told of any; hence, 
although the CGM may be helpful for this enrollee, given the data provided, we do not have enough 
information to say that coverage criteria are met. If additional data is available, it should be provided and the 
case re-reviewed. 
 
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 continuous glucose monitor (CGM) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve FreeStyle Libre 2
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 rendered on March 6, 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 the block was part of the procedure along with the general anesthesia. 
 
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 64447 is "Injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve." 
 
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 in this case medical 
documentation does not include sufficient documentation to support service billed.  A peripheral block was given for post operative pain at 16:20 and Spinal block was given in operating room at 4:07, which was prior to 
post operative pain management service. 
 
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 procedure code 64447 rendered on March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you and your provider both agree a 
LTACH admission is necessary. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466) for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that the non-invasive ventilator will improve the
enrollee's quality of life. The Plan denied your request. The Plan says that the documentation does not support
that the use of a CPAP or BiPAP device would not meet the enrollee's medical needs and there is no
documentation that BiPAP with average volume-assured pressure support (AVAPS) has been found to be
ineffective.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a home ventilator.
Our Medical Director states that the documentation does not support that the coverage criteria established by
Medicare rules were met in this case. Medicare rules state that payment policy requirements preclude FSS
payment for devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the
illness treated by the device. This means that products currently classified as HCPCS code E0465 or E0466
when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying
medical condition, shall not be paid in the FSS payment category. A ventilator is not eligible for reimbursement
for any of the conditions described in Medicare rules even though the ventilator equipment may have the
capability of operating in a bi-level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or
bi-level CPAP therapy for conditions described in this Medicare rules will be denied as not reasonable and
necessary. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for a home
ventilator.

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) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880, 93882). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that this is medically 
necessary. 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 a duplex scan of extracranial arteries. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical documentation indicates the enrollee is asymptomatic. 
There is no clinical rationale for the requested study. 
 
   
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880, 93882).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) (G6001 x 5). 
 
You asked the Plan to pre-approve the IGRT. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested therapy 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 IGRT. Our reviewer says that the 
requested IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the image-guided radiation therapy (G6001 x 5) meets all Medicare 
criteria for medically reasonable and necessary and safe and effective for the patient. Current peer-reviewed 
treatment guidelines do not support the use of image-guided radiation therapy in this clinical scenario. 
Therefore, the reviewer found that the requested IGRT 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 IGRT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve image-guided radiation therapy (IGRT) (G6001 x 5).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a position emission-computed tomography (PET/CT) 
scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are medically necessary to find 
out if your cells have spread. The Plan denied your request. The Plan says you have not had treatment for your 
prostate cancer according to your records received. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan. Our reviewer says 
that the PET/CT scan is not medically necessary. Our physician reviewer found the record indicates that you 
have been recently diagnosed with prostate cancer. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a position emission-computed tomography (PET/CT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve Sprint PNS. You say that the Plan's denial is unwarranted and unsupported. 
The Plan denied your request. The Plan says this is not medically necessary as it is not being requested for a 
trial of a permanently implanted stimulator. 
 
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 Sprint PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy for shoulder pain and is the subject of ongoing clinical 
trials. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint peripheral nerve stimulator (PNS).