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

 
We decided that the Plan does not have to pre-approve Optimizer Smart System (Heart Contractility 
Modulation System) 
 
You asked the Plan to pre-approve Optimizer Smart System. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are 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 Optimizer Smart System. 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 chronic Heart Failure with Reduced Ejection Fraction (15% per most 
recent echo), due to non-ischemic/dilated cardiomyopathy, NYHA class 2. The Cardiac Contractility 
Modulator (optimizer device) is still in the investigational phase and not recommended by any professional and scientific societies or organization as a part of heart failure management guidelines. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Optimizer Smart System (Heart Contractility Modulation System)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 21, 2022, to 
January 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid. The Plan denied your request. The Plan says the Plan has changed the DRG from 551 to 552. 
 
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 I50.23 acute on chronic systolic (congestive) heart 
failure. 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 inpatient stay does not meet criteria for payment at the DRG 
originally billed. Our physician reviewer found the documentation does not consistently and completely 
support the assigned secondary diagnosis code. The decision to remove the secondary diagnosis code and 
adjust the DRG was correct.  
 
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 January 21, 2022, to January 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nasal valve collapse with low energy 
radiofrequency subcutaneous/submucosal remodeling. 
 
You asked the Plan to pre-approve the requested nasal surgery. You say that it is felt that this is the best option 
for the enrollee at this time.  The Plan denied your request. The Plan says there has not been sufficient 
conservative treatment at this time.  
 
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 nasal surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case.  
Our physician reviewer found the documentation does not support that the requested procedure is medically 
reasonable and necessary for the enrollee in this case, as there is insufficient documentation of trial and failure of conservative therapy. 
 
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 nasal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repair of nasal valve collapse with low energy radiofrequency 
subcutaneous/submucosal remodeling.
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 the enrollee will need intensive therapy services 
from both physical therapy and occupational therapy and requires oversight by a rehabilitation physician. 
The Plan denied your request. The Plan says the enrollee's records do not show that they have complex 
rehabilitation needs that require frequent evaluation by a rehab doctor. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ipilimumab and nivolumab. 
 
You asked the Plan to pre-approve ipilimumab and nivolumab. You say that the records provided support the 
need for the requested drugs.  The Plan denied your request. The Plan says use of these drugs for the enrollee's 
cancer would need to be FDA approved or have positive support in certain resources. The use of ipilimumab 
and nivolumab for (lung cancer is not FDA approved or listed in the Medicare approved sources after disease 
progression while on PD-1/PD-L1 inhibitor. The Plan also says records show that the enrollee received this 
type of treatment before. During the time of treatment or right after, the enrollee's cancer got worse. Having the 
same treatment again does not meet the criteria for coverage.  
 
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 ipilimumab and nivolumab. Our 
reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the enrollee has 
progression of disease on prior immunotherapy. The National Comprehensive Cancer Network (NCCN) 
Guidelines specifically dissuade using PDL1 inhibitors after progression on another PDL1 inhibitor.  The 
combination of ipilimumab and nivolumab is recommended for 1st line therapy and not after progression of 
disease. The service is not reasonable or medically necessary for the enrollee in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ipilimumab and nivolumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ipilimumab and nivolumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from October 25, 2021, to October 30, 2021. 
 
 
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 a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim was supported clinically. 
 
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 A41.9. 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 enrollee presented with nausea and vomiting in the setting of diabetes and 
gastroparesis. The enrollee was treated for gastroparesis and a urinary tract infection. There is no evidence of 
hypotension, hypoperfusion or organ failure. As such, a diagnosis of sepsis 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 billed with diagnosis code A41.9 rendered from October 25, 2021, to October 30, 
2021.
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 the services are medically necessary for the enrollee.  
The Plan denied your request. The Plan says the enrollee does not require intensive therapy services.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to move due to several incisions in 
your abdominal area and need rehab therapy to regain strength and vitality. The Plan denied your request. The 
Plan says the services that you need can be provided safely in another setting such as a skilled nursing facility, 
home with home health services or home with outpatient therapy. 
 
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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 6, 2022, to 
November 9, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was appropriately 
admitted on an inpatient basis. The Plan denied your request. The Plan says that inpatient level of care was not 
medically necessary. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case.  Our physician 
reviewer found the enrollee presented to the emergency department with a complaint of facial swelling and 
vomiting. Testing and imaging was performed and no acute events occurred during the admission. Imaging 
showed a slightly worsened retropharyngeal swelling compared to a prior study and distal subclavian vein 
narrowing, but no occlusion. Outpatient otolaryngology follow-up was recommended and the enrollee was 
discharged on November 9, 2022. At the time of admission the admitting physician reasonably expected that 
the enrollee's necessary hospital care (including earlier emergency department and/or observation) would span 
at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 6, 2022, to November 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that your research shows that this 
device is FDA and Medicare approved. The Plan denied your request. The Plan says there is a lack of evidence 
on the efficacy of interspinous fixation devices as a stand-alone procedure for those who have spinal stenosis 
and/or spondylolisthesis.  
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show 
safety and efficacy  
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of rituximab. 
 
You asked the Plan to pre-approve rituximab. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says there aer not enough studies to prove this is needed for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say 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.  
 
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 rituximab. Our reviewer says that the 
enrollee does not meet criteria for rituximab. Our physician reviewer found rituximab is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the 
major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rituximab have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of rituximab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial ankle with swing phase active dorsiflexion 
(L5968) and flex-walk system (L5981) for a lower limb prosthesis. 
 You asked the Plan to pre-approve lower limb prosthetic components. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that coverage of lower limb prosthetic components is 
based on an assessment of the enrollees functional level. 
 
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 lower limb prosthetic components. Our 
reviewer says that the enrollee does not meet criteria for these components. Our physician reviewer found the 
documentation does not support that the enrollee is able to ambulate at a functional level 3. There is no clear 
documentation to support that the enrollee requires upgraded components. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a multiaxial ankle with swing phase active dorsiflexion (L5968) and 
flex-walk system (L5981) for a lower limb prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes A41.9 
and G93.41 rendered from December 12, 2020, to December 18, 2020. 
 
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 a post-service, post-payment Clinical 
Validation Audit was performed to ensure that the diagnosis codes on the claim were supported clinically. 
 
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 codes A41.9 and G93.41. 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 in this case, there was no clinical or laboratory evidence of of A41.9 (sepsis, 
unspecified organism) and G93.41 (metabolic encephalopathy) The review has determined that the 
documentation did not support diagnosis code A41.9 or G93.41. The record more supports DRG 194.  
 
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 billed with diagnosis codes A41.9 and G93.41 rendered from December 12, 
2020, to December 18, 2020.
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 service is medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical condition 
does not require the requested 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are 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 long term acute care hospital (LTACH) services.