Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that you disagree with the 
denial and have submitted additional clinical notes to support the request. The Plan denied your request. The Plan says based on the clinical information provided, the enrollee has not had any syncopal episodes (have not 
passed out). 
 
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 implantable loop recorder (ILR). 
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 a history of atrial fibrillation. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ICM. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ICM in this enrollees 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 an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wrist blood pressure monitor. 
 
You asked the Plan to pre-approve a wrist blood pressure monitor. You say that you need this device because 
your heart beats fast sometimes and you want to be able to monitor yourself. The Plan denied your request. The 
Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that a standard blood pressure monitor would not meet your needs. Therefore, we 
decided that the Plan does not have to pre-approve a wrist blood pressure monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim NEO device.  
 
You asked the Plan to pre-approve the Barostim NEO device. You say that the Barostim NEO device is 
medically necessary. The Plan denied your request. The Plan says the Barostim NEO device 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 the Barostim NEO device. Our 
reviewer says that the requested Barostim NEO device is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the Baroreflex stimulation devices have been considered potential 
alternative treatments for resistant hypertension and heart failure. The Barostim Neo system is an electronic 
pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors 
of one of the carotid arteries. In August 2019 the Food and Drug Administration (FDA) approved the system 
for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-
directed medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not candidates 
for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily 
activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an 
absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value 
of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in this enrollees 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 Barostim NEO device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Barostim NEO device.
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 time to improve. The Plan denied your 
request. The Plan says all needed services are available in the current inpatient rehabilitation facility. 
 
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 record shows that you have been receiving skilled rehab services in an inpatient 
rehabilitation facility (IRF). You have tolerated inpatient rehab services and continue to improve with daily 
skilled services. You could benefit from continued services at the current level of care, but there are no services 
offered at a SNF that are not offered at an inpatient rehabilitation 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 that you did not require any skilled services on an inpatient basis, at a skilled level of 
care as of June 30, 2023. You did not require parental medications, complex wound care, or nutrition given via 
a feeding tube. You were at or near your prior level of function and could be discharged to a lower level of care 
for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary breast cancer-related disorders; genomic 
sequence analysis panel (81432). 
 You asked the Plan to pre-approve genomic sequence analysis panel. 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 effective for services performed on or after January 
27, 2020, CMS has determined that NGS as a diagnostic laboratory test is reasonable and necessary and 
covered nationally for patients with germline (inherited) cancer, when performed in a CLIA-certified 
laboratory, when ordered by a treating physician and when all requirements are met. 
 
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 genomic sequence analysis panel. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case the 
requested test is not reasonable and necessary because the enrollee does not have a clinical indication for 
germline testing for hereditary breast or ovarian cancer. The review has determined that the enrollee does not 
meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genomic sequence analysis panel have not been met. Therefore, we decided that 
the Plan does not have to pre-approve hereditary breast cancer-related disorders; genomic sequence analysis 
panel (81432).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27590 provided on July 26, 2022. 
 
You asked the Plan to pay for procedure code 27590. You say that the medical records support the billing of 
code 27590. The Plan denied your request. The Plan says the medical records do not support the billing of code 
27590. 
 
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 27590 is Amputation, thigh, through femur, any level. 
 
We asked our coder 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 procedure code 27590. Our reviewer says that the medical 
records do not support the billing of code 27590. Our reviewer found the records submitted do not support CPT 
code 27590. The records consist of a pathology report and order results. There is no operative report supporting that the amputation of the leg through the femur was performed as billed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27590 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27590 provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L5-S1 medial branch block (MBB) procedure 
(64493). 
 
You asked the Plan to pre-approve injections. You say that the enrollee has been under your care since 
February 10, 2023, for the treatment of chronic intractable axial low back pain. This treatment is reasonably 
expected to reduce or ameliorate the disability and assist the enrollee in achieving maximum functional 
capacity in performing daily activities. The Plan denied your request. The Plan says the enrollee has low back 
and leg pain possibly due to lumbar stenosis. Her pain is not predominantly axial. Therefore, medial branch 
block 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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have classic facet joint pain symptoms and has leg pain. The medial 
branch block is not medically necessary for 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve bilateral L5-S1 medial branch block (MBB) procedure (64493).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you are requesting reconsideration due 
to history of atrial fibrillation. The Plan denied your request. The Plan says the records do not show that the 
enrollee is able to tolerate or receive dual antiplatelet therapy or anticoagulation therapy for one month post, 
implantation. The records show the enrollee's BMI is > 25 and does not show her chest circumference. The 
request 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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor 
device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management 
of enrollees with CHF. The clinical study on which FDA approval was based showed improved clinical 
outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was implanted, 
reflecting an enrollee population with preserved ejection fraction and was somewhat limited in scope. 
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with 
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. It does not appear that this enrollee has chronic carbon dioxide (CO2) retention, and therefore does 
not meet criteria for a ventilatory assist device. If the enrollee were to develop chronic CO2 retention, 
documented with an arterial blood gas (ABG) done while stable, they would likely benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee has not had a 4-week trial of use 
of an E0650 or E0651 pneumatic compression device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 26, 2022, to 
July 25, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA is on file with the Plan. The 
Plan denied your request. The Plan says a valid NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 28, 2022. A valid NOA was not received by the Plan. As more than 
30 days passed since the timely filing date, no payment can be made on this claim. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from June 26, 2022, to July 25, 2022.
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 believe that you need to be back in the SNF.  
The Plan denied your request. The Plan says criteria for SNF admission have not been met.  
 
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 have a medical history of hypertension and diabetes and were discharged from a 
SNF on June 16, 2023, with home health services. You are now requesting re-admission to the SNF. The most 
recent therapy notes show that you are able to ambulate household distances with a walker at the time of 
discharge from the SNF. You require some assistance with daily self-care task from a caregiver. 
 
The records show that you do not require skilled nursing and/or skilled therapy services on a daily basis. You 
are medically stable, and while you would benefit from additional therapy, this can be provided on an 
intermittent basis at a lower 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378). 
 You asked the Plan to pre-approve a diagnostic colonoscopy. You say that you recommend repeating a 
colonoscopy for colon cancer screening in five years due the enrollee's unknown family history. You also say 
that the enrollee is now overdue for a colonoscopy. The Plan denied your request. The Plan says the concern 
for family history of colon cancer in an enrollee who was adopted would be heightened prior to the age of 50 to 
ensure not missing early age colon cancer. The Plan also says the enrollee has had 2 normal colonoscopies after 
the age of 50, and as such, this colonoscopy request is denied. 
 
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 diagnostic colonoscopy. 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 no personal history of adenomatous polyps or colon cancer, of 
inflammatory bowel disease, or multiple polyposis syndromes. Three prior colonoscopies between 2006 (at age 
53), 2011, and 2018 have been identified with no high-risk features. Our reviewer also found that the 5-year 
time frame requested for a repeat colonoscopy does not meet medical appropriateness nor necessity criteria 
given the enrollee's "non-high risk for colon cancer" status. 
 
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 diagnostic colonoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a diagnostic colonoscopy (45378).