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

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the CardioMEMS device has been determined to be of uncertain value 
and carries a risk of significant complications including death and severe pulmonary artery injury. The 
CardioMEMS device at this point should only be approved for enrollees enrolled in a clinical trial. There is no 
indication that this enrollee is enrolled in a clinical trial of the device. 
 
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 is still a research device and has no proven clinical benefits 
in any randomized clinical trials and are still not recommended by heart failure treatment guidelines. 
 
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 (33289, C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion or replacement of the Optimizer Smart 
permanent cardiac contractility modulation system (0408T).  
 
You asked the Plan to pre-approve the Optimizer Smart permanent cardiac contractility modulation system. 
You say that without intervention, the enrollee remains at risk for additional heart failure hospitalization with a 
poor prognosis. The Plan denied your request. The Plan says a review of the current medical literature indicates 
that this service is considered experimental and investigational.  
 
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 Optimizer Smart permanent cardiac 
contractility modulation system. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the Cardiac Optimizer device is still of unproven clinical benefits in the randomized Clinical trials and considered a 
research/experimental device and not approved by the professional societys treatment guidelines for the 
treatment of heart failure. 
 
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 Optimizer Smart permanent cardiac contractility modulation system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of 
the Optimizer Smart permanent cardiac contractility modulation system (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 the office visit provided 
on December 28, 2022.
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 regarding the 
denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the acute IRF 
setting have not been met. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be assessed both medically and 
functionally in regard to pre-morbid functional capacity to determine whether the enrollee will benefit from a 
rehabilitation level of care offered by mentioned facility. The Plan denied your request. The Plan says the 
records do not show the enrollee will be able to tolerate or fully participate in the intensity of three hours of 
daily therapies provided in the IRF setting. 
 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. 
 
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 pantoprazole tablets. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve pantoprazole tablets.
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 needs this device. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 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. 
 
 
 
 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 a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Multiple orders and copies of 
medical records have been provided in this case. The initial order from June 28, 2023, and records dated June 
23, 2023, reported that the home ventilator was being requested for use in average volume assured pressure 
support (AVAPS) mode. A later order from July 10, 2023, reported the ventilator mode was to be synchronized 
intermittent mandatory ventilation pressure control (SIMV-PC) and the clinical records at that time for the 
same June 23, 2023, visit note made no mention of AVAPS mode (or SIMV-PC mode). AVAPS mode is a 
modality which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revo dial system (L5999). 
 
You asked the Plan to pre-approve the revo dial system. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the revo dial system. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this item has not been proven safe and effective for this member's condition. 
 
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 revo dial system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the revo dial system (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(E0303). 
 
You asked the Plan to pre-approve a hospital bed. You say that you are appealing the denial and the medical 
records support the necessity of the requested service. The Plan denied your request. The Plan says the enrollee 
does not meet the weight limit criteria or the requested hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. The records show that the enrollee's weight is 305 pounds. Based on 
this information, we decided that Medicare rules for coverage of a hospital bed have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not reveal the rationale for this invasive imaging study. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
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 as this 
enrollee meets the full criteria for an IRF stay. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve omeprazole. 
 
You asked the Plan to pre-approve omeprazole. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve omeprazole.   
Benefits for omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology procedure provided on 
January 06, 2023. 
 
You asked the Plan to pay for an unlisted molecular pathology procedure. You say that this service was 
medically necessary. 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 unlisted molecular 
pathology procedure provided on January 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment delivery for plantar warts  
(Heelex treatment). 
 
You asked the Plan to pre-approve radiation treatment delivery for plantar warts (Heelex treatment). You say 
that radiation treatment delivery for plantar warts is medically necessary. The Plan denied your request. The 
Plan says radiation treatment delivery for plantar warts 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 radiation treatment delivery for plantar 
warts. Our reviewer says that the requested radiation treatment delivery for plantar warts (Heelex treatment) is 
not considered medically reasonable and necessary. Our physician reviewer found there is insufficient literature 
showing superior results and safety with radiation treatment versus other more proven treatments for plantar warts (ex: chemical peels, laser, excision, electrosurgery, cryosurgery, cantharidin, bleomycin, immunotherapy) 
to support this request. There were no special circumstances suggesting a contraindication to approved 
treatments. Therefore, this request for Heelex treatment 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 radiation treatment delivery for plantar warts (Heelex treatment) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve radiation treatment delivery for plantar 
warts (Heelex treatment).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 You asked the Plan to pre-approve Darzalex Faspro. You say that the requested drug is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Bortezomib or Velcade.  
 
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 Darzalex Faspro. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has tried and failed the preferred drugs, Bortezomib or Velcade. The reviewer also 
found that there is no documentation provided indicating that the plan's required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 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 Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested are 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 the enrollee is receiving acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that they are not currently receiving but that 
would be available at the LTACH facility. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee. The documentation does not 
support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.