Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories 
(E0953, E0955, E1007, E1012, E1028, E2209, E2311, E2313, E2361, E2377, E2607, E2620, K0040, K0108). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the requested power wheelchair and 
accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollees 
condition does not require a Group 3 power wheelchair as they have adequate strength to manage standard 
power drive controls. The enrollee does not have a high risk for skin breakdown. The enrollee also does not 
require intermittent catheterization and does not have spasticity. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories (E0953, 
E0955, E1007, E1012, E1028, E2209, E2311, E2313, E2361, E2377, E2607, E2620, K0040, K0108).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of a subcutaneous cardiac rhythm monitor, including 
programming. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's inconclusive non-invasive 27 days of holter monitoring may be assisted by an 
implantable loop recorder in deciding about the risk of full anti-coagulation discontinuation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve insertion of a subcutaneous cardiac rhythm monitor, including programming.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the specific type of device exceeds the enrollee's medical need. 
 
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 the requested ventilator. Our reviewer 
says that the requested ventilator is not medically necessary. Our physician reviewer found the records show that this device is to be used in a setting that can be provided by a bilevel positive airway pressure (BiPAP) 
device with average volume-assured pressure support (AVAPS). 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 the requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in a tremendous amount of pain 
and cannot function. The Plan denied your request. The Plan says the enrollee has a contraindication. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided single-photon emission computed tomography (SPECT) study of the thoracic spine 
from 4/14/23 and the x-rays from 3/17/23 were not able to conclude that the compression deformity is acute or 
subacute. Additionally, there is no indication of progression of vertebral body height loss or more than 25% 
vertebral body height reduction. Therefore, the enrollee does not meet the inclusion criteria for kyphoplasty. 
Additionally, the enrollee has some of the exclusion criteria, as the imaging from 4/14/23 identified other 
potential causes of the pain. Additionally, the study also demonstrated osseous retropulsion causing mild spinal 
canal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on 
November 29, 2022. 
 
You asked the Plan to pay for FoundationOne CDx (F1CDx) testing. You say that this testing was medically 
necessary and reasonable. The Plan denied your request. The Plan says this test was not medically necessary 
for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is coverable when medically necessary 
for patients meeting certain clinical criteria. 
 
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 FoundationOne CDx (F1CDx) testing. Our 
reviewer says that FoundationOne CDx (F1CDx) testing was not medically necessary. Our physician reviewer 
found this patient is felt to have 2 syncronous lung primaries of low stage. No clinical information is supplied 
to rationalize NGS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FoundationOne CDx (F1CDx) testing have not been met. Therefore, we decided 
that the Plan does not have to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on November 
29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MinuteMan fusion plate system. 
 
You asked the Plan to pre-approve the MinuteMan fusion plate system. You say that the MinuteMan fusion 
plate system offers the patient a less invasive procedure and is an alternative to pedicle screw placement. The 
Plan denied your request. The Plan says the MinuteMan fusion plate system is not medically necessary when 
used as a standalone lumbar vertebral fusion procedure. More studies are needed to show this system is 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 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 MinuteMan fusion plate system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the MinuteMan decision is considered experimental.  More research is needed before this device can be considered reasonable and 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 MinuteMan fusion plate system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the MinuteMan fusion plate system.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on January 9, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered. 
 
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 DEX Diagnostics Exchanges shows that this testing is 
listed as covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
provided on January 9, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperthermic intraperitoneal chemotherapy (HIPEC) services. 
 
You asked the Plan to pre-approve HIPEC services. You say that the records provided support the need for 
HIPEC services. The Plan denied your request. The Plan says that the clinical value and effectiveness of 
HIPEC in the setting of colon cancer have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 HIPEC services. Our reviewer says that 
HIPEC services are considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has peritoneal carcinomatosis from colon cancer. In select patients diagnosed with metastatic 
spread to the peritoneum, Colorectal surgery and HIPEC have the potential to be curative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIPEC services have been met. Therefore, we decided that the Plan has to pre-
approve hyperthermic intraperitoneal chemotherapy (HIPEC) services.  
 
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 pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management.  
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CardioMEMS device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that the documentation provided supports the need 
for the requested procedure. The Plan denied your request. The Plan says the requested procedure is not 
supported by research. 
 
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 RFA services. Our reviewer says that 
RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has chronic low back pain and sacroiliitis. The enrollee has medication trials of Oxycodone and 
Tizanidine. The enrollee is doing a home exercise program. The magnetic resonance imaging (MRI) shows 
spinal stenosis at L4 to S1 and prior laminectomy at L5-S1. The enrollee had bilateral sacroiliac joint injections. The first produced 80% pain relief for one week and the second 80% for 3 days. The requested 
procedure is considered experimental because of the wide variation in efficacy reported in the peer reviewed 
literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 units of procedure code 87801 billed for date of service 
May 26, 2022. 
 
You asked the Plan to pay for the services. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says the number of units billed is not supported in the 
medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
laboratory report does not support the three units billed. This procedure requires reporting one unit when any 
two or more codes are reported.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for 3 units of procedure code 87801 billed for date of service May 26, 2022.
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 records provided support that 
LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH services are not 
medically necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee at this time. The 
Plan says that the enrollee can remain in the current acute care location until such a time that no further acute 
level care is needed. 
 
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says the records do not show that the enrollee requires daily skilled 
nursing or skilled therapy in a SNF setting. The Plan says that the services needed are custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says additional physical therapy is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
prior therapy approved (a total of 20 sessions), and the documentation does not reveal that you require the 
unique skills of a professional therapist to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition, or to prevent or slow further deterioration. You can be instructed in a home exercise program, with 
the already approved 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.