Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of left atrial 
appendage (LAAC) device (33380). 
 You asked the Plan to pre-approve LAAC device. You say that the requested procedure is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the conditions for 
coverage. 
 
The Plan follows Medicare rules. Medicare rules say that left atrial appendage closure (LAAC) devices are 
covered when the device has received Food and Drug Administration (FDA) Premarket Approval (PMA) for 
that devices FDA-approved indication and meet all of the conditions for coverage are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve LAAC device. Our reviewer says that 
the requested LAAC device is not medically necessary. Our physician reviewer found the provided 
documentation indicates the enrollee has a history of atrial fibrillation and a stroke risk (CHADS2VASC) score 
less than 3. As such, guidelines would not support implantation of a LAAC in this setting. Therefore, the 
reviewer found that the requested LAAC device is not medically reasonable or necessary 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 LAAC device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous transcatheter closure of left atrial appendage (LAAC) device (33380).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve twenty-eight (28) fractions of intensity-modulated radiation 
therapy (IMRT) (77386, 77387, G6002, G6015) and eight fraction boost with image-guided radiation therapy 
(IGRT). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that IMRT bladder cancer criteria are not met. The Plan states it appears 
that IMRT was requested due to size of the field, overlying small bowel, and the toxicity benefit demonstrated 
in clinical trials for anal cancer not bladder cancer. 
 
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 items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT would be furnished in accordance with accepted standards of medical practice. 
 
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 twenty-eight (28) fractions of intensity-modulated radiation therapy (IMRT) (77386, 77387, G6002, 
G6015) and eight fraction boost with image-guided radiation therapy (IGRT).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for a seat lift mechanism have not been 
met. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Specifically, the provided records do not document that 
you are completely unable to stand up from a regular armchair or any chair in the home. Therefore, we decided 
that the Plan does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the surgery. You say that the procedure will be beneficial for the enrollee to 
help reduce pain and improve quality of life. The Plan denied your request. The Plan says given the enrollee's 
diagnoses of severe spinal stenosis, spondylolisthesis, risk factors for osteoporosis, and lack of improvement in 
the enrollee's pain with flexion, this device is contraindicated for the enrollee. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vestibuloplasty (D7340), the removal of torus palatinus 
(D7472), and the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat very well. The Plan denied 
your request. The Plan says that vestibuloplasty (D7340), the removal of torus palatinus (D7472), and the 
removal of torus mandibularis (D7473) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
vestibuloplasty (D7340), the removal of torus palatinus (D7472), and the removal of torus mandibularis 
(D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left-hand scar revision with skin graft procedure 
(14041, 15275). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that please reconsider this denial given 
that this is not a wound that will completely heal without surgical intervention. The Plan denied your request. 
The Plan says the use of the Stravix membrane to allow for better healing after a z-plasty does not appear 
appropriate or the standard of care, with no medical literature or prospective studies showing health outcome 
benefits as of yet. 
 
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 outpatient procedure. 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 (Dupuytren's contracture and 
requires surgical intervention. The requested device is planned to be used during the surgical procedure. The 
record indicates that the enrollee has nicotine addiction. The provided record does not document that the 
requested product will be used in clinical conditions as described in the coverage rules. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the left-hand scar revision with skin graft procedure (14041, 15275).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of 
osteoporotic fracture or has tried and failed zoledronic acid. The documentation does not support that 
zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the 
enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says back pain is not primarily due to a vertebral compression fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for spondylolisthesis of the lumbar region and osteoporotic 
compression fracture of the spine. Detailed documentation is not evident regarding the age of the computed 
tomography (CT) scan corroborated T12 compression fracture. The fracture was noted to be mild. Additionally, 
the CT scan corroborated additional plausible causes of the noted lower back and left flank pain. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested kyphoplasty at T12, in this case, is not indicated for the 
enrollees 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Injectafer (J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has tried one of the preferred drugs (Ferrlecit, Infed or Venofer) and it has notworked, or that the 
enrollee has medical reasons that prevent the enrollee from using one of them. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Ferrlecit, Infed or Venofer before they will approve the requested drug. 
In this case, the enrollee has not tried and failed a required drug. There is no documentation provided indicating 
that the Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Injectafer (J1439).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader. 
 
  You asked the Plan to pre-approve a FreeStyle Libre 2 reader. You say that the enrollee is unable to perform 
fingerstick reading. You also say that you would like to help the enrollee keep a tight control of their glucose. 
The Plan denied your request. The Plan says a CGM is not covered under Medicare if the member does not 
have documentation of history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee is not insulin treated 
and does not have documentation of a history of problematic hypoglycemia. Based on this information, we 
decided that Medicare rules for coverage of a FreeStyle Libre 2 reader have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery 
(22869). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are 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 the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a lower level of care in your area cannot 
provide intermittent hemodialysis on patients with a new tracheostomy. The Plan denied your request. The Plan 
says the request is 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require IRF services in order to get stronger after 
your heart surgery. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 3, 2022, to 
March 4, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 3, 2022. The NOA was not received by the Plan until June 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from February 3, 2022, to March 4, 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 the services are medically necessary for the 
enrollee's rehab needs. The Plan denied your request. The Plan says the enrollee can receive physical therapy 
and occupational therapy in a less intensive setting, such as a skilled nursing facility or in-home. 
 
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.