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

 
We decided that the Plan does not have to pre-approve left hip synovectomy. 
 
You asked the Plan to pre-approve left hip synovectomy.. You say that you have been in pain constantly for 
two months and are limited in your movements without relief. You said that you feel surgery would greatly 
improve your daily living and you were very active prior to your injury. The Plan denied your request. The 
Plan says the requested left hip synovectomy is not medically necessary. Per medical literature, synovectomy 
would be medically necessary in the setting of inflammatory arthritis in the absence of osteoarthritis. Per the 
records received and imaging results, there is no documentation of hip joint synovitis. 
 
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 left hip synovectomy.. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have been treated for a strain of muscle fascia and tendon of the left hip. You 
presented with left hip pain and have difficulty walking and significant discomfort. Your medical exam 
revealed tenderness to palpation over your greater trochanter with some weakness with the gluteus is noted. 
You have some slight impingement symptoms. However, the provided magnetic resonance imaging (MRI) of 
the left hip did not corroborate synovitis of the left hip. Additionally, the MRI did note mild left hip joint 
arthrosis, a small effusion and other plausible causes of your ongoing left hip pain. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested left hip synovectomy, in this case, 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 left hip synovectomy. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left hip synovectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure (B4150). 
 
You asked the Plan to pre-approve Ensure. The Plan denied your request. The Plan says formula by mouth is 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
 
 
 The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure (B4150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the requested item is necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare says this item is not reasonable and necessary 
based on a lack of evidence. Medicare says that a crutch substitute, such as a knee walker, has not been proven 
to be safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We looked at the file and Medicare rules. Medicare says there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these 
products. The requested item is not a covered benefit. Based on this information, we decided that Medicare 
rules for coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crutch substitute, lower leg platform, with or without wheels (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
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 mechanical ventilator. Our 
reviewer says that you do not need this item. Our physician reviewer found The Life2000 system is not a true ventilator, because it is not capable of providing full ventilatory support.  There is inadequate evidence of the 
safety and efficacy of this device in the treatment of COPD. 
 
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 mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 21, 2022, 
through June 23, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9- (Sepsis unspecified 
organism).. 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 documentation does not support the primary diagnosis of 
A41.9- (Sepsis unspecified organism). Our physician reviewer found that the member presented with urinary 
symptoms and a fever. The member was found to have a urinary tract infection (UTI), dehydration and anemia. 
The member received intravenous ceftriaxone, antibiotics, blood transfusions and pulse-dose steroids. There is 
no evidence that the member had hypo perfusion or organ failure, related to the urinary tract infection (UTI). 
As such, the billing of A41.9 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 provided on June 21, 2022, through June 23, 2022, and billed with diagnosis 
code A41.9.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 26, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mastectomy for gynecomastia (19300). 
 
You asked the Plan to pre-approve the mastectomy for gynecomastia. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that mastectomy with nipple preservation or reduction 
mammoplasty is considered reconstructive and a covered service for males with gynecomastia Grade III and IV 
or abnormal breast development with redundancy.  
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 mastectomy for gynecomastia. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has gynecomastia.  The record provided indicates that the enrollee is taking spironolactone and 
cessation of the drug has not been trialed. 
 
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 mastectomy for gynecomastia have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the mastectomy for gynecomastia (19300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has challenges with 
finger sticking with a traditional glucose monitor. You said that this item is needed to prolong the enrollee's 
kidney function and avoid dialysis. The Plan denied your request. The Plan says the enrollee doesn't meet 
coverage criteria for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is 
medically necessary. You say that other options have been unsuccessful. The Plan denied your request. The 
Plan says hyperbaric oxygen therapy is not medically necessary per the Medicare NCD. 
 
The Plan follows Medicare rules. Medicare rules say that no program payment may be made for HBO in the 
treatment of  chronic peripheral vascular insufficiency. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested hyperbaric oxygen therapy is not considered medically necessary in this case. 
Our physician reviewer found that you have chronic non-pressure ulcers related to chronic peripheral venous 
insufficiency. However, the provided documentation does not clearly describe your ulcers/wounds as being 
caused by diabetes, the wound being infected with a difficult to treat infection, or other required condition to 
meet the Medicare NCD coverage criteria. Vascular insufficiency is not a covered condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom wheelchair back cushion (E2617), hardware 
(E0955), headrest (E1028), manual swingaway (K0739). 
 
You asked the Plan to pre-approve the wheelchair features. You say that the items should be covered. The Plan 
denied your request. The Plan says the cost of repair outweights the cost of replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair features have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the custom wheelchair back cushion (E2617), hardware (E0955), headrest (E1028), manual 
swingaway (K0739).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and has been on a home ventilator since 2020. He was hospitalized and an arterial 
blood gas (ABG) showed a normal partial pressure of carbon dioxide in arterial blood (PaCO2) of 36, but a 
subsequent ABG showed a PaCO2 of 58. There are no pulmonary function tests to confirm airways obstruction 
or assess severity. There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no 
ABG done while stable to document chronic CO2 retention. The criteria for coverage are not met and the home 
ventilator is therefore 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 home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 4, 
2022, to August 5, 2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that it is clear the services provided to 
the enrollee were medically necessary, reasonable, and provided at the appropriate inpatient level of care. The 
Plan denied your request. The Plan says the enrollee had no documentation of complications related to an 
ambulatory surgical procedure, complex postoperative course, or need for treatment that could not be 
appropriately provided in an ambulatory setting. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee was admitted for elective total knee replacement on August 4, 
2022, and was discharged on August 5, 2022. There were no notable surgical complications. Our reviewer 
found that the record does not show that at the time of inpatient admission, the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 
care) would span two midnights. Our physician reviewer also found that an inpatient admission was 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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from August 4, 2022, to August 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory panel testing billed for date of service 
December 30, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory panel testing billed for date of service December 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of chest. 
 
You asked the Plan to pre-approve the CT of the chest. You say that the services are medically necessary and 
being requested outside of the year time frame. The Plan denied your request. The Plan says this imaging is 
only supported once per six months for three years after the disease was found, then once a year after that. 
Records indicate that the CT was last performed on March 9, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT of the chest. Our reviewer says 
that the CT scan of the chest is not medically necessary. Our physician reviewer found the enrollee has a 
history of early-stage breast cancer that was diagnosed in 2018 and at least a 40-pack year history of smoking. 
The enrollee had a CT of the chest ordered for their history of smoking with a chronic cough. A CT of the chest 
with contrast would not be indicated for screening for lung cancer which uses a low dose CT with no contrast.  
 
 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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of chest.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (U0005, U0003) provided on August 
25, 2022. 
 
You asked the Plan to pay for the COVID-19 testing. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says additional documentation is needed to determine if testing was medically 
necessary. 
 
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 COVID-19 testing have been met. 
Medical records are necessary to review the medical necessity of the testing. The Plan made multiple attempts 
to obtain this information but it was not received. Without this information we are unable to review if the 
testing was medically necessary.  Therefore, we decided that the Plan does not have to pay for the COVID-19 
testing (U0005, U0003) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regenerate per site (D4266), bone replacement graft per site (D7953), bone graft for implant placement (D6104), implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065) for tooth #15.
You asked the Plan to pre-approve these services. You say that you have an infection in your mouth, the tooth is broken, and it needs to be removed. The Plan denied your request. The Plan says that these services are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue regenerate per site (D4266), bone replacement graft per site (D7953), bone graft for implant placement (D6104), implant placement (D6010), prefabricated abutment (D6056) and implant supported crown (D6065) for tooth #15.