Persius/hicric huggingface dataset:
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving the care needed in the current facility. 
 
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 record indicates that the enrollee has ongoing acute medical issue and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastectomy and nipple/areola reconstruction. 
 
You asked the Plan to pre-approve mastectomy and nipple/areola reconstruction. 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 follows Medicare rules. Medicare rules say that Medicare considers reduction mammaplasty 
reconstructive for gynecomastia.  
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 mastectomy and nipple/areola 
reconstruction. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
provided records in this case do not document gynecomastia of grade III or IV as defined on the ASPS 
gynecomastia scale or abnormal breast development with redundancy that has persisted more than 3 to 4 
months after pathological causes are ruled out or unsuccessful medical treatment for pathological 
gynecomastia. Records document no pain or tenderness directly related to the breast tissue which has a 
clinically significant impact upon activities of daily living and the symptoms are refractory to a trial of 
analgesics or anti-inflammatory agents. Records document no significant clinical manifestations due to the 
excessive breast weight adversely affecting the supporting structures of the shoulders, neck, and trunk as 
required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mastectomy and nipple/areola reconstruction have not been met. Therefore, we 
decided that the Plan does not have to pre-approve mastectomy and nipple/areola reconstruction.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
osteoarthritis of the left knee with x-ray evidence. There is no documentation of trial and failure of exercise, 
weight loss, and physical therapy over a three-month period. The records do not support that Euflexxa is safe 
and effective and 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 Euflexxa.
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 admission is a medical 
necessity. The Plan denied your request. The Plan says the records do not show that the enrollee has care needs 
which require an LTAC level of care.  
 
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 progress notes from November 20, 2023 indicate there have been attempts to wean 
the enrollee from the ventilator, but there are no dates of spontaneous breathing trials noted. There is no 
documentation provided indicating medical necessity for admission to a LTACH.  The enrollee does not require services at the LTACH that are not available at the acute care hospital where 
currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and are 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for footwear and related charges purchased on dates of service 
May 29, 2023, to July 15, 2023. 
 
You asked the Plan to pay for the footwear. You say that you had a prescription from your doctor for these 
shoes.  You said that you paid out of pocket for these items. The Plan denied your request. The Plan says you 
purchased these items from providers that are not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the providers you 
used are not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for 
footwear and related charges purchased on dates of service May 29, 2023, to July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine studies of heart muscle at rest and 
with stress and single-photon emission computed tomography (SPECT). 
 
You asked the Plan to pre-approve nuclear medicine studies of heart muscle at rest and with stress and SPECT. 
You say that it is medically necessary. The Plan denied your request. The Plan says it 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 nuclear medicine studies of heart 
muscle at rest and with stress and SPECT. 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 no 
cardiac symptoms and does not benefit from any kind of stress test.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nuclear medicine studies of heart muscle at rest and with stress and SPECT 
have not been met. Therefore, we decided that the Plan does not have to pre-approve nuclear medicine studies 
of heart muscle at rest and with stress and single-photon emission computed tomography (SPECT).
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 you cannot get out of bed on your own, cannot walk 
unaided, and cannot get to a bathroom or bedside commode on your own,  you continue to need appropriate 
pain medication and are a fall risk. You say 24-hour rehabilitation care is most appropriate at this time. The 
Plan denied your request. The Plan says the notes do not show that your care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that you have complex 
care needs that require a coordinated team approach; the notes do not show that you must have an intensive 
therapy program (3 hours a day, at least 5 days a week) in order to improve self-care functioning.   
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and can be provided in a 
lower level of care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care with C1-C2 decompression and 
fusion surgery (22595, 22840, 63001). 
 
You asked the Plan to pre-approve inpatient hospital care. You say that you are requesting reconsideration due 
to medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee has 
evidence of myelopathy, cord compression, spinal instability, or fracture at the C1-C2 level. Because the 
requested surgery is not medically necessary, neither is the associated hospital stay. 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient hospital care is met in this case. Our 
physician reviewer found there is no need for an inpatient hospital stay for C1-2 fusion surgery. This is a 
routine case that can be done with a 48-hour observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital care with C1-C2 decompression and fusion surgery (22595, 
22840, 63001).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 15, 2023, to May 
10, 2023. 
 You asked the Plan to pay for the home health services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from April 15, 
2023, to May 10, 2023.
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 you need this care to return home safely. The Plan 
denied your request. The Plan says your condition does not meet the criteria for an IRF admission.  
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 
care needs can be met at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you request reconsideration as Keytruda is 
medically necessary for the enrollee's treatment for head and neck cancer. The Plan denied your request. The 
Plan says the claims for routine costs associated with this clinical trial should be submitted to Original 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Keytruda as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Keytruda (J9271).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cogenex amniotic membrane (Q4229). 
 
You asked the Plan to pre-approve Cogenex amniotic membrane. You say that medical records have been 
provided to support the medical necessity. 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 Cogenex amniotic membrane. Our 
reviewer says that the requested Cogenex amniotic membrane is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided records do not include any operative reports 
from the Mohs procedure to support the need for the skin substitute in this case. The argument for use of the 
skin substitute consists only of a letter of medical necessity. The reviewer also found that skin substitute usage in Mohs surgery reconstruction is not well-guided. Therefore, the reviewer found that the requested Cogenex 
amniotic membrane 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 Cogenex amniotic membrane have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cogenex amniotic membrane (Q4229).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6.  
You asked the Plan to pre-approve a continuous glucose monitor (CGM).. You say that the enrollee needs this 
CGM. The Plan denied your request. The Plan says the medical criteria for a CGM have 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.  
Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor 
(CGM). have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VNS device. 
 
You asked the Plan to pre-approve a VNS device. You say that a VNS device is medically necessary to regain 
use of your left hand/arm after the stroke and after all conservative therapies. The Plan denied your request. 
The Plan says the requested VNS device does not meet the Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a VNS device is covered when the criterial listed in 
the Medicare rules section of this decision 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 a VNS device. Our reviewer says that 
the requested VNS device is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Effective for services performed on or after July 1, 1999, VNS is reasonable and 
necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or 
for whom surgery has failed. Effective for services performed on or after February 15, 2019, the Centers for 
Medicare & Medicaid Services (CMS) will cover FDA-approved VNS devices for treatment resistant 
depression (TRD) through Coverage with Evidence Development (CED) when offered in a CMS-approved, 
double-blind, randomized, placebo-controlled trial." The provided records do not document that you have a 
covered medical indication for the VNS device per the Medicare NCD 160.18.  
 
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 VNS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a VNS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 10, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary and 
supported by the medical records. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of total knee arthroplasty (27486, 27487). 
 
You asked the Plan to pre-approve revision of total knee arthroplasty. 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 follows Medicare rules. Medicare rules say that replacement/revision knee arthroplasty is considered 
reasonable and necessary when certain 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 revision of total knee arthroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no evidence 
of component loosening or infection. There is no clinical indication for revision surgery 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 revision of total knee arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve revision of total knee arthroplasty (27486, 27487).