Persius/hicric huggingface dataset:
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 is not able to walk and the requested IRF 
services are necessary for the enrollee to regain their strength and become independently mobile. The Plan 
denied your request. The Plan says the notes do not show that the enrollee's care specifically requires the 
involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show that the enrollee has 
complex care needs that require a coordinated team approach; the notes do not show that the enrollee must 
have an intensive therapy program (3 hours a day, at least 5 days a week) in order 
to improve self-care functioning.   
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services.  There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve the mediation. You say that the enrollee needs this medication to prevent 
any infections caused by cytopenia. The Plan denied your request. The Plan says the requested treatment order 
of Fulphila is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the mediation. Our reviewer says that 
the requested use of Fulphila is not FDA approved for the enrollees diagnosis. Our physician reviewer found 
that the use of Fulphila 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 the mediation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Fulphila.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unattended home sleep test (HST) with a type III 
portable monitor (G0399). 
 
You asked the Plan to pre-approve the monitor. You say that the monitor is medically necessary. The Plan 
denied your request. The Plan says the clinical information provided does not indicate that the enrollee has 
observed apneas (stopped breathing), choking or gasping during sleep, a measured neck circumference and, a 
completed and abnormal score on the Epworth Sleepiness Scale. The Plan states the request for an 
authorization for a home sleep study has been denied. 
 
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 monitor. Our physician reviewer 
found although the enrollee has somnolence, there is not substantial evidence to support sleep apnea nor 
HST. Therefore, there is no indication for HST. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an unattended home sleep test (HST) with a type III portable monitor (G0399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device used for cancer 
treatment, includes all accessories (E0766). 
 
You asked the Plan to pre-approve an electrical stimulation device. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show the enrollee does not have a newly diagnosed glioblastoma multiforme. The use of 
tumor treatment field therapy for any indications other than newly diagnosed glioblastoma multiforme will be 
denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electrical stimulation device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided, there is no documentation that the 
TTFT at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and 
effective for the enrollee. Provided records in this case do not document the enrollee has a histologically 
confirmed (World Health Organization (WHO) grade IV astrocytoma), newly diagnosed, supratentorial 
glioblastoma multiforme (GBM), as is required by LCD L34823. The LCD goes on to say: "The use of TTFT 
for any indications other than newly diagnosed GBM will be denied as not 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 an electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electrical stimulation device used for cancer treatment, includes all 
accessories (E0766).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Epifix. 
 
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 remains denied as experimental, investigational, and not medically necessary. 
 
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 has a non-healing wound from a surgical procedure. Multiple other avenues have been 
taken to attempt to safely close it without success. Therefore, Epifix is medically 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 services have been met. Therefore, we decided that the Plan has to pre-
approve Epifix.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided by an out-of-network 
(OON) provider on July 11, 2023. 
 
You asked the Plan to pay for the OON psychotherapy services. You say that the enrollee has been seeing this 
provider since 2016 and that the services provided were medically necessary. The Plan denied your request. 
The Plan says the provider is not in-network with the Plan and there is no documentation of a prior 
authorization request. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON psychotherapy services. Our 
reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the 
provided records do not document that the enrollee was receiving any active treatment and/or medical 
management of their condition that made it medically necessary to be continuing care with the OON provider. 
There is nothing unique about the enrollee's condition that would make it medically necessary to continuate 
care OON. The Plan has shown that they had network specialists who have the qualifications and expertise 
necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. The 
enrollee's medical management and/or follow-up care could have been transitioned to an in-network specialist. 
 
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 OON psychotherapy services have not been met. Therefore, we decided that 
the Plan does not have to pay for psychotherapy services provided by an out-of-network (OON) provider on 
July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is at high risk for hospital 
readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of a ventilator. 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and was 
recently hospitalized with an exacerbation. An arterial blood gas was consistent with acute on chronic 
hypercarbic respiratory failure. The enrollee has had home BiPAP previously but was noncompliant. A hospital 
note indicates the enrollee refuses to try BiPAP again. There is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. This enrollee may benefit from BiPAP with average volume-assured pressure support 
(AVAPS) during sleep as an outpatient if tolerance can be achieved. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous fusion. 
 
You asked the Plan to pre-approve interspinous fusion. You says this procedure is approved and covered by 
Medicare nationwide and should be covered under the enrollees policy. You say that this procedure is a 
minimally invasive procedure over a significantly more invasive open, lumbar surgical decompression and 
fusion procedure utilizing rods and screws. The Plan denied your request. The Plan says this procedure is 
unproven and not covered by Medicare due to insufficient evidence of efficacy. 
 
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 interspinous fusion. Our reviewer says 
that the requested interspinous fusion is not considered medically reasonable and necessary. Our physician 
reviewer found that interspinous fusion devices are experimental. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interspinous fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve interspinous fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim device. 
 
You asked the Plan to pre-approve the Barostim device. You say that the Barostim device is appropriate as the 
member has failed guideline-directed medical therapy. The Plan denied your request. The Plan says the 
Barostim device is insufficiently proven with the available 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 the Barostim device. Our reviewer says 
that the requested Barostim device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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 FDA approved the system for use in patients with refractory heart 
failure who remain symptomatic despite treatment with guideline-directed medical therapy, are 
New York Heart Association (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 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 Barostim device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Barostim device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sensor (A9276) and a receiver (A9278) provided on June 
19, 2023. 
 
You asked the Plan to pay for the sensor and receiver. You say that the device is necessary to monitor your 
blood sugar while sleeping. The Plan denied your request. The Plan says the requested items are a non-covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that products reviewed by the PDAC which do not 
meet the DME benefit category requirements must be coded as A9276, A9277, A9278, or A9279 and will be 
denied as non-covered (no Medicare Benefit). 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sensor and receiver have not been met. Therefore, we decided that the Plan does not have to 
pay for a sensor (A9276) and a receiver (A9278) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for seat lift mechanism, electric, any type (E0627) 
non-covered item or service (A9270) sales tax (S9999) purchased March 10, 2023. 
 
You asked the Plan to reimburse you for the seat lift mechanism. You say that this was denied but per the EOC 
the chair is covered, and you are owed 80% of the approved amount.  The Plan denied your request. The Plan 
says the seat lift mechanism is not a covered benefit under the Plan and is not approved.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 reimburse you for the seat lift mechanism. 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 require a power seat lift chair per guideline criteria. 
The enrollee is noted to have no difficulties with standing, ambulating, or performing her daily activities. There 
is limited documentation regarding the enrollee's specific level of mobility and ability to perform transfers and 
there is no indication of severe osteoarthritis of the hip or knee joints or a severe neuromuscular disease. 
Therefore, the requested power seat lift chair (E0627) is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Code A9270 indicates that the item is not 
covered and therefore not payable by Medicare. Code S9999 is a recognized code for purposes of reporting 
sales tax but is not payable. Based on this information, we decided that Medicare rules for coverage of the seat 
lift mechanism have not been met. Therefore, we decided that the Plan does not have to reimburse you for seat 
lift mechanism, electric, any type (E0627) non-covered item or service (A9270) sales tax (S9999) purchased 
March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing billed with code 81479 for date of 
service July 4, 2023. You asked the Plan to pay for Guardant360. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code was submitted with a correct DEX-Z test 
identifier; however, the CPT code used to report this test does not align with the code assigned by the MolDX 
program. 
 
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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the DEX Diagnostics 
Exchange Registry confirms that the Z-Code used was appropriate; however, the CPT code for this test is listed 
as 0326U. It is not appropriate to use an unspecified code when there is a more specific/accurate code 
available. Based on this information, we decided that Medicare rules for coverage of Guardant360 have not 
been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing billed with code 
81479 for date of service July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with 
procedure codes 57065-59-51, 46917, and 56515-59. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 57065-59-51, 46917, and 56515-59 is destruction of 
vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery), destruction of 
lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery, 
and destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery). 
 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical records provided does 
not include sufficient documentation to validate that the billed services were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with procedure codes 
57065-59-51, 46917, and 56515-59.