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

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you want the Plan to approve these benefits. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2022, billed 
with codes 81162, 81201, 81249, 81295, 81298, 81307, 81317 and 81325. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 27, 2022, billed with codes 81162, 81201, 81249, 81295, 81298, 81307, 81317 and 81325.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you are requesting an appeal for the denial of a 
home ventilator. The Plan denied your request. The Plan says the clinical information provided did not show 
documentation to support the need for the ventilator versus a BIPAP. 
 
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 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has chronic respiratory failure from chronic 
obstructive pulmonary disease.  The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with AVAPS capability and failure of such a device has not been documented.  The elements 
of the coverage criteria are not satisfied.   
 
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 home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this is necessary for your safety. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the CardioMEMS device. 
 
You asked the Plan to pre-approve implantation of the CardioMEMS device. You say that the CardioMEMS 
device is Food and Drug Administration (FDA)-approved and is effective for the patient's condition. The Plan 
denied your request. The Plan says implantation of the CardioMEMS device is not medically necessary and 
reasonable. 
 
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 implantation of the 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 patients with congestive heart failure. The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient 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 patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate 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 implantation of the CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of the CardioMEMS device.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee can receive the care needed at a skilled nursing facility. 
 
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 treatment by multiple therapies. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that they would meet criteria for admission to an acute inpatient 
rehabilitation facility. The enrollee can receive further services 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 21, 
2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Herceptin Hylecta (J9356). 
 
You asked the Plan to pre-approve Herceptin Hylecta. You say that the enrollee refused intravenous therapy. 
The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
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 Herceptin Hylecta. Our reviewer says 
that the requested use of Herceptin Hylecta is medically necessary. Our physician reviewer found though the 
Food and Drug Administration (FDA) has not approved the requested use of Herceptin Hylecta, there is 
medical literature that does. The reviewer found that a limited proportion of patients will need an alternative 
treatment approach, either because of contraindications or their preference. In these situations, trastuzumab 
monotherapy, eventually combined with endocrine agents, might be a reasonable option offering favorable 
long-term outcomes by addressing the high-risk profile associated with HER2-positive disease. Therefore, the 
reviewer found that the requested use of Herceptin Hylecta is medically reasonable 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 Herceptin Hylecta have been met. Therefore, we decided that the Plan has to 
pre-approve Herceptin Hylecta (J9356).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthroscopic left knee surgery to include 
meniscectomy and debridement (29880, 29881).  
You asked the Plan to pre-approve the arthroscopic left knee surgery to include meniscectomy and 
debridement. You say that the service is medically necessary. The Plan denied your request. The Plan says the 
service 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. The following procedures are not considered reasonable or necessary in treatment of 
the osteoarthritic knee and are not covered by the Medicare program: 
 
Arthroscopic lavage used alone for the osteoarthritic knee; 
Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or, 
Arthroscopic debridement and lavage with or without debridement for patients presenting with severe 
osteoarthritis  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the arthroscopic left knee surgery to include meniscectomy and debridement have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the arthroscopic left knee surgery to include 
meniscectomy and debridement (29880, 29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there was no documentation submitted to support medical necessity 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CPAP device have been met. There was no documentation submitted to support medical necessity.. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have insomnia. The Plan denied your 
request. The Plan says based on Medicare guidelines, the device to assist with breathing (home noninvasive 
ventilator-NIV) requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item is not medically necessary. Our physician reviewer found that you were hospitalized in early 
August 2020 with respiratory failure and improved on bilevel positive airway pressure (BiPAP). Notes from 
that hospitalization indicate that you were noncompliant with the ventilator prior to admission. The records do 
not include any device downloads to assess compliance since then. There are no arterial blood gases, done 
while stable, to document chronic CO2 retention. There is a venous blood gas from January 6, 2022, showing a 
pH of 7.34 and a PvCO2 of 79.  If you do have chronic CO2 retention, it is likely related to obesity 
hypoventilation syndrome. You may benefit from c ontinuous positive airway pressure (CPAP) or BiPAP 
during sleep. Medicare does not cover a home ventilator when used in the treatment of obesity hypoventilation 
syndrome, or when used at settings that can be provided with BiPAP. Also, you are not using the device 
enough to be beneficial. 
 
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, any type, used with non-invasive interface (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 21 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional 21 PT visits. You say that you are still in a lot of pain and 
your x-ray show that you have 2 bulging disks. The Plan denied your request. The Plan says it appears that you 
have reached your maximum level of function. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional 21 PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of your condition. Our physician reviewer found you had prior therapy, and the documentation does not reveal 
that you require the unique skills of a professional therapist to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. The plan approved additional visits which will 
ensure that you have been thoroughly trained in a home exercise program. Ongoing formal therapy is not 
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 the additional 21 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 21 physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 21, 2022, 
through May 24, 2022, and billed with diagnosis code N17.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis N17.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of N17.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code N17.9-Acute kidney failure, 
unspecified. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
N17.9-Acute kidney failure, unspecified. Our physician reviewer found the member presented with chronic 
abdominal pain, in the setting of a known endovascular leak. The member was found to have hyponatremia. 
There is no evidence of overt renal failure. The billing of N17.9 is not supported.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 21, 2022, through May 24, 2022, and billed with diagnosis 
code N17.9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's life is in danger without this 
device. The Plan denied your request. The Plan says based on Medicare guidelines, the device to assist with 
breathing (home noninvasive ventilator-NIV) requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 this item is not medically necessary. Our physician reviewer found that the enrollee was recently 
hospitalized with pneumonia and an acute exacerbation of chronic obstructive pulmonary disease (COPD).  
Arterial blood gas (ABG) was consistent with severe acute on chronic hypercarbic respiratory failure. The 
enrollee improved on bilevel positive airway pressure (BiPAP) and then average volume-assured pressure 
support (AVAPS). There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  There is no 
ABG done while stable to confirm chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with AVAPS during sleep as an outpatient. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve StimQ peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve StimQ PNS. You say that the enrollee has tried to alleviate pain with 
conventional treatment including nerve blocks and pharmacological therapies. You also say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 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 StimQ PNS. Our reviewer says that the 
requested StimQ PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of STIMQ PNS for low back pain is considered experimental. There is not enough 
evidence in the peer reviewed literature that this an effective therapy. Therefore, the reviewer found the request for StimQ PNS is not 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 StimQ PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve StimQ peripheral nerve stimulator (PNS) (64555).