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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device 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. 
 
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 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee has diagnoses of heart failure, obstructive sleep apnea and chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. Provided records document that the home 
ventilator is being requested for use in a pressure support mode with safety tidal volume which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured 
pressure support (AVAPS) and a back-up rate. The provided records in this case do not provide adequate 
detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with 
AVAPS and a back-up rate. Therefore, the enrollee does not meet criteria for the requested device. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an ESI. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections are only covered when there is 
shown to be at least 50% of sustained improvement in pain relief and/or improvement in function measured 
from baseline using SAME scale for at least three months. 
 
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 ESI. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee a history of low back pain with bilateral leg pain due to lumbar radiculopathy and lumbar spinal stenosis without neurogenic claudication. Magnetic resonance imaging 
showed severe spinal stenosis at L3-L4 and L4-L5. The enrollee had improvement status post epidural steroid 
injection (ESI) on June 27, 2023, however, the enrollees pain returned to a pain level of nine out of 10. The 
enrollee has also taken non-steroidal anti-inflammatory drugs/Tramadol/Gabapentin and had physical therapy, 
home stretching, heat/ice, and rest/inactivity. The enrollee was seen in follow-up on July 13, 2023. The 
documentation does not support that there was at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three months. In addition, there 
was no documentation that the provider would be using a different approach, level and/or medication for the 
requested repeat ESI. Therefore, the enrollee does not meet criteria for the requested injections. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram provided on October 05, 2022. 
 
You asked the Plan to pay for an electroencephalogram. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an 
electroencephalogram provided on October 05, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that you have knee problems. You say that your knee 
starts to lock. You also say that you need this medication. The Plan denied your request. The Plan says you 
have not tried and failed the preferred drugs, Orthovisc or Supartz FX. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that you have tried and failed the preferred drugs, Orthovisc or Supartz FX. The reviewer also found 
that there is no documentation provided supporting that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for you. Therefore, the reviewer found that the step therapy criteria have not 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869, 
C1821).  
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous device. You say that you are unable to 
walk or stand for a short period of time without pain and cannot function in daily life.  The Plan denied your 
request. The Plan says you do not meet criteria for coverage. 
 
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 Vertiflex Superion Interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is 
needed. Thus, this procedure is not considered medically reasonable and 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 the Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (22869, C1821).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 18, 2023, to 
discharge. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the entire length of stay was medically 
necessary. The Plan denied your request. The Plan says this stay was not medically necessary after June 17, 
2023. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there was insufficient information provided to support the extended stay from June 
18, 2023, to discharge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided June 18, 2023, to discharge.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device 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. 
 
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 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document 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 documentation in this 
case do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as 
opposed to a BiPAP device with AVAPS and a back-up rate. Therefore, the enrollee does not meet criteria for 
the requested device. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve permanent cardiac contractility modulation system, the 
Optimizer Smart device (CCM). 
 
You asked the Plan to pre-approve permanent cardiac contractility modulation system, the Optimizer Smart 
device (CCM). You say that permanent cardiac contractility modulation system is medically necessary. The 
Plan denied your request. The Plan says the requested permanent cardiac contractility modulation system 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 permanent cardiac contractility 
modulation system. Our reviewer says that the requested permanent cardiac contractility modulation system is 
not considered medically reasonable and necessary in this case. Our physician reviewer found that ab exhaustive review of the current medical literature pertaining to the CCM system confirms multiple 
observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus 
control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM 
providing meaningful improvement in quality-of-life scores and objective functional capacity. While the 
clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-
term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, I would not consider the CCM system to be medically necessary in this 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 permanent cardiac contractility modulation system, the Optimizer Smart device 
(CCM) have not been met. Therefore, we decided that the Plan does not have to pre-approve permanent cardiac 
contractility modulation system the Optimizer Smart device (CCM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on January 23, 2023. 
 
You asked the Plan to pay for a home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit evaluation 
provided on January 23, 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 will benefit from an IRF admission to 
optimize their functional level before returning home. The Plan denied your request. The Plan says the 
documentation does not indicate the enrollee's status supports an active participation in or benefit from 
rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require intensive or complex rehabilitation to address residual 
deconditioned state. The enrollee does not require frequent physiatry oversight. The documentation provided 
does not reveal that an IRF admission is 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 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a 4 Digit Point Design Finger, Mechanical, Standard, Body 
Powered Device. 
 
You asked the Plan to pre-approve a 4 Digit Point Design Finger, Mechanical, Standard, Body Powered 
Device.. You say that this item is medically necessary. The Plan denied your request. The Plan says that the 
requested device exceeds the member's need. 
 
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 a 4 Digit Point Design Finger, 
Mechanical, Standard, Body Powered Device. Our reviewer says that the requested items are considered 
medically reasonable and necessary in this case. Our physician reviewer found the passive functional prosthesis 
is a basic device for restoring bimanual function and provides significant impact on overall wellbeing. 
 
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 4 Digit Point Design Finger, Mechanical, Standard, Body Powered Device. 
have been met. Therefore, we decided that the Plan has to pre-approve a 4 Digit Point Design Finger, 
Mechanical, Standard, Body Powered Device.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Aloxi (J2469), Emend (J1453, and 
Cisplatin (J9060). 
 
You asked the Plan to pre-approve Keytruda, Aloxi, Emend, and Cisplatin. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Keytruda, Aloxi, Emend, and Cisplatin. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found Keytruda is 
medically reasonable and necessary in combination with chemotherapy, with or without bevacizumab, for 
patients with persistent, recurrent or metastatic cervical cancer whose tumors express programmed cell death 
ligand 1 (PD-L1) (CPS?=1), as determined by an FDA-approved test. There is no sign of persistent cervical 
cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Aloxi, Emend, and Cisplatin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda (J9271), Aloxi (J2469), Emend (J1453, and 
Cisplatin (J9060).
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an SNF.  
 
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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on March 30, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says this test is not covered by Medicare and is not 
considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no coverage for CPT codes 0012M and 
0013M for CxBladder.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare coverage rules 
have not been met. Specifically, the service at issue is explicitly non-covered. Therefore, we decided that the 
Plan does not have to pay for CxBladder testing (0012M) provided on March 30, 2022.