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

 
We decided that the Plan does not have to pre-approve a ProACT adjustable continence therapy device 
(53451). 
 
You asked the Plan to pre-approve a ProACT device. You say that you feel the enrollee would benefit greatly 
from this procedure. The Plan denied your request. The Plan says this device is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ProACT device. Our reviewer says 
that the requested ProACT device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device at issue is experimental and investigational. The reviewer found that it has 
not been scientifically demonstrated to be as safe and effective as conventional treatment. The ProACT device does not appear to be an ideal device for durable continence and patients satisfaction. The reviewer found that 
additional studies are needed. Therefore, the reviewer found that the requested device 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 a ProACT device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ProACT adjustable continence therapy device (53451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), urinalysis (81000), and catheter 
insertion (51702) provided on January 10, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that you are upset that you have not been 
reimbursed for these services. You also say that they took place on a cruise ship. The Plan denied your request. 
The Plan says no proof of payment has been provided for the services in this case. 
 
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 outpatient services have been met. 
There has been no evidence that payment was made for the services in this case. The Evidence of Coverage 
clearly states that proof of payment must be submitted to the Plan for reimbursement. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), urinalysis (81000), and catheter insertion (51702) 
provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast cancer index testing.  
You asked the Plan to pre-approve a breast cancer index testing. You say that given the pathology, the enrollee 
is eligible for Brest Cancer Index testing to see if they would benefit from additional 5 years of endocrine 
therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria as the 
enrollee has a HER2+ result. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of a breast cancer index testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a breast cancer index testing.
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 skilled nursing level of care will not give the best 
opportunity to regain the enrollee's baseline quality of life. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive rehabilitation to 
address their deficits impacting their strength. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met at an alternate level of care.  
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary.  
The Plan denied your request. The Plan says the enrollee does not meet criteria for the HFCWOD. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for the HFCWOD. Our physician reviewer found provided medical records 
document a diagnosis of bronchiectasis, but records do not include the computerized tomography report 
confirming this. Provided medical records do not document the enrollee presently uses a mechanical in-
exsufflation device (E0482) and plans to continue to do so. Provided medical records do not document failure 
of standard treatments to adequately mobilize retained secretions. Provided records repeatedly document that 
the enrollee "denies cough or productive cough." 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653, billed for 
date of service January 18, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, and 87653. The Plan denied your request. 
The Plan says payment for codes 87150, 87481, 87641, and 87653, is bundled. 
 
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, we have confirmed that code 87150 
is a column II code to column I code 87641. We have also confirmed that codes 87481, 87641, and 87653, are 
column II codes to column I code 87500. This claim has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653, billed for date of service 
January 18, 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 the enrollee meets Medicare criteria for acute 
inpatient rehabilitation and will benefit from acute inpatient rehab that cannot be accomplished at a lower level 
of care. The Plan denied your request. The Plan says the enrollee's records do not show that you need an 
intensive team for your care. Services needed may be provided safely in a lower level of care. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure at L3, L4, and L5. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says this procedure 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging showing only modic changes without 
facet degenerative joint disease or foraminal stenosis. The cause of the enrollee's back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure at L3, L4, and L5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can only walk a short distance with a 
walker. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollees needs can be met at an alternate level of care.  
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Elotuzumab and Carfilzomib. 
 
You asked the Plan to pre-approve the drugs. You say that  The Plan denied your request. The Plan says 
Elotuzumab and Carfilzomib is not medically necessary.  
 
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 the drugs. Our reviewer says that 
Elotuzumab and Carfilzomib is not medically necessary. Our physician reviewer found that the enrollee has a 
diagnosis of multiple myeloma and has not achieved remission. The requested drugs Elotuzumab and 
Carfilzomib is not FDA-approved for the enrollees condition. Elotuzumab and Carfilzomib is also not 
supported by one of the major drug compendia or by clinical research. Therefore, the elements of the coverage 
criteria 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Elotuzumab and Carfilzomib.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain. 
 
You asked the Plan to pre-approve the PET scan. You say that this procedure is necessary to secure the 
diagnosis of their dementia type. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee was only identified as 
having a dementia. According to the applicable NCD, a PET scan of the brain is covered for use in individuals 
who meet diagnostic criteria for both AD and FTD. The record provided does not establish that the enrollee 
meets the diagnostic criteria of both AD and FTD. Therefore, a PET scan cannot be covered 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan of the brain.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on February 11, 2023. 
 
You asked the Plan to pay for the office visit. You say that the weekend before your dental appointment your 
face swelled up and you were in severe pain from an infected tooth and could not reach your dentist over the 
weekend. You say that you went to your primary medical clinic for help where they prescribed antibiotics for 
the infection and to ease the swelling and pain until you could get into the dentist the following week. The Plan 
denied your request. The Plan says that the service or item in question is not covered under the member's 
contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Plan rule, a valid Medicare rule or a 
coding rule to substantiate denial for an urgent office visit with a network provider for an infection. Therefore, 
we decided that the Plan has to pay for an office visit provided on February 11, 2023.  
 
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 pay for a pneumatic compression device (PCD) and accessories 
(E0652, E0656, E0667). 
 
You asked the Plan to pay for the PCD and accessories. The Plan denied your request. The Plan says this is not 
medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652 used to treat lymphedema not 
extending onto the chest, trunk and/or abdomen or CVI is not eligible for reimbursement. Claims will be denied 
as not 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 pay for the PCD and accessories. Our reviewer says 
that the requested PCD and accessories are not medically reasonable and necessary. Our physician reviewer 
found that the enrollee has lymphedema secondary to post-phlebitis syndrome. She does not have ulcers on her 
legs. The requested PCD and accessories arenot medically necessary to treat lymphedema secondary to chronic 
venous insufficiency. 
 
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 PCD and accessories have not been met. Therefore, we decided that the Plan 
does not have to pay for a pneumatic compression device (PCD) and accessories (E0652, E0656, E0667).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service November 11, 2020, to 
December 1, 2020. 
 
You asked the Plan to pay for the billed services. You say that the visits meet the coverage criteria. The Plan 
denied your request. The Plan says that OASIS assessments were not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The records provided do include an OASIS assessment as required to 
support the physical therapy services. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan 
has to pay for the home health care billed for dates of service November 11, 2020, to December 1, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 30, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that the claim could not be submitted 
within the required time because the patients complete/updated information was not received in time. The Plan 
denied your request. The Plan says the claim denial is correct as there was ample time for the provider to 
submit a corrected claim after initial claim denial notice. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physical therapy services was not filed until February 6, 2023. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on 
December 30, 2021.
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 a home ventilator. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. Our physician reviewer found that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-
up rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
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.