Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for an 
LTACH admission. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says that admission to an LTACH is not medically necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has multiple active medical problems including renal failure requiring dialysis and 
complex wound care. The enrollee's inpatient care needs will likely meet or exceed 25 additional days. The 
enrollee appears to be stable for transfer to an LTACH.  
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH 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: 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 you need this care. The Plan denied your request. 
The Plan says medical records do not support the need for an SNF admission and, your needs can be safely 
provided at another setting. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is now ready to transition to 
the LTACH where they will benefit from long term acute care hospitalization to regain maximum prior level of 
functioning and a continued multi-disciplinary approach to care. The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary.  
 
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 that the enrollee has ongoing acute medical issues and still requires acute care 
service. Also, there is no indication that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. 
 
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83970 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for the billed service. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed service cannot be verified. 
 
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, the CPT Code Manual definition of code 83970 is parathormone (parathyroid hormone). We find 
that CPT code 83970 is not supported in the medical record. The records do not show that the test was 
performed by the billing provider. The records show that a separate lab performed the testing at issue. Based on 
this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 83970 billed for date of service 
May 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vidaza. 
 
You asked the Plan to pre-approve Vidaza. The Plan denied your request. The Plan says Vidaza 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 Vidaza. Our reviewer says that Vidaza 
is not medically necessary. Our physician reviewer found that the requested Vidaza is not FDA- approved. 
Vidaza is also not supported by one of the major drug compendia or by clinical research. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vidaza have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Vidaza.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that  medical records were provided. The Plan 
denied your request. The Plan says the billed codes cannot be verified.  
 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, the CPT Code Manual definition of code 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes. We find that CPT codes 80307 and G0483 are not 
supported in the medical record. The records show that a urine all-in-one panel test was ordered. The records 
do not specifically show that presumptive testing was ordered. The records do not show what specific drug 
classes were ordered, or that 22 or more drug classes were needed based on clinical documentation. Blanket 
orders are not a covered benefit. 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 procedure codes 
80307 and G0483 billed for date of service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve Venofer. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 Venofer. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was noted to have stable anemia, and the provided documentation did not show 
failure or intolerance to oral iron intake/supplementation or contraindication to such to justify intravenous (IV) 
iron infusion. The coverage criteria is not met. Therefore, this request for Iron sucrose injection will be considered not medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Venofer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Venofer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the lumbar radiofrequency ablation. 
 
You asked the Plan to pre-approve  the lumbar radiofrequency ablation. You say that you have severe chronic 
back pain that limits your daily activities.  The Plan denied your request. The Plan says the lumbar 
radiofrequency ablation is not medically necessary. The Plan says the records do not show that you have a 
minimum of 50% improvement in pain for at least six months or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living.  
 
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 lumbar radiofrequency ablation. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found previous injection therapy results are not clearly documented and do not show at 
least 70% improvement for three to six months after injection 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 lumbar radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve  the lumbar radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC) (33340).  
You asked the Plan to pre-approve placement of a LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED) with 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 placement of a LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found while there is reference to 
consideration of the LAAC, there is no documentation of performance of an evidence-based shared decision-
making interaction on anticoagulation. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this 
patient's 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 placement of a LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC) (33340).
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 home ventilator. You say that the medical records provided support the 
need for the requested home ventilator. The Plan denied your request. The Plan says based on Medicare 
guidelines, the non-invasive ventilator (NIV) requested does not meet the requirements for approval.  
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee does not have 
documented failure of BiPAP and essentially was prescribed CPAP. Hence, does not require home ventilator 
support per documentation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection. 
 
You asked the Plan to pre-approve repeat epidural steroid injection. You say that this is medically necessary 
and did help the enrollee with their pain the first time. The Plan denied your request. The Plan says this does 
not meet the LCD criteria for coverage. 
 
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 repeat epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found it has been less than 3 
months since the members last ESI at the same location. Additionally, the member has not attempted physical 
therapy for her latest symptoms of low back pain and, therefore, there is no documentation of either an inability 
to tolerate or a failure of conservative management. The review has determined that the enrollee does not meet 
the LCD criteria for coverage. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a luxury portable oxygen concentrator.  
 
You asked the Plan to pre-approve a luxury portable oxygen concentrator. You say that you are frail and are 
using a walker which makes it hard for you to carry the current oxygen concentrator from your apartment to the 
dining area downstairs. You say that you need assistance to wheel the concentrator. The Plan denied your 
request. The Plan says a luxury portable oxygen concentrator is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 luxury portable oxygen concentrator 
Our reviewer says that a luxury portable oxygen concentrator is not medically necessary. Our physician 
reviewer found the medical records do not show that the SpO2 can be maintained above 91% during activity on 
the portable oxygen concentrator, or on an oxygen conserving device, at a flow rate of 1 to 4 L/min, which is a 
Medicare requirement. If that requirement could be met, the lightweight portable oxygen concentrator would be 
considered 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 a luxury portable oxygen concentrator have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve a luxury portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee requires daily physician, 
nursing, and therapy services. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an LTACH admission. 
 
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 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 level of care that are not 
available at the acute care hospital in which they are currently receiving care. The requested LTACH services 
are not medically appropriate for the diagnosis and condition of the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve deep gum and root cleaning on upper right, upper left, lower right, 
lower left quadrants (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning on upper right, upper left, lower right, lower 
left quadrants. You say that you are on blood thinners and need this procedure because you haven't been to the 
dentist for a while. The Plan denied your request. The Plan says that this does not meet the criteria for 
coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers deep gum and 
root cleaning on upper right, upper left, lower right, lower left quadrants when the services are medically 
necessary and reasonable. 
 
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 deep gum and root cleaning on upper 
right, upper left, lower right, lower left quadrants. Our reviewer says that the service is medically necessary. 
Our physician reviewer found a review of the documentation submitted indicates the presence of periodontal 
pockets of 4-7mm in all quadrants with bleeding when probed. This indicates the presence of periodontal 
disease. Scaling and root planing in four quadrants is medically reasonable and necessary to treat the patient's 
periodontal disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of deep gum and root cleaning on upper right, upper left, lower right, lower left 
quadrants have been met. Therefore, we decided that the Plan has to pre-approve deep gum and root cleaning 
on upper right, upper left, lower right, lower left quadrants (D4341).  
 
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 home ventilator. You say that the submitted medical prescription and the 
records show that the enrollee was using a BiPAP in the hospital but that they want the non-invasive ventilation 
(NIV) for home use.  The Plan denied your request. The Plan says  this request 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee documentation 
show appropriate response and compliance with BiPAP. There is no indication of failure or requirement for 
increased BiPAP or ventilatory support.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.