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

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC) (93355, 33340). 
 You asked the Plan to pre-approve placement of an LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that 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 certain conditions. 
 
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 placement of an LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no apparent 
contraindication to anticoagulation. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically 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 placement of an LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC) (93355, 33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 12, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Radiosurgery (SRS) (77372, 77470). 
 
You asked the Plan to pre-approve SRS. You say that the enrollee has a life-threatening illness and needs the 
therapy as soon as possible. The Plan denied your request. The Plan says that the request does not meet the 
Medicare/LCD or health plan coverage criteria. 
 
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 SRS. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found brain SRS is medically necessary for this enrollee presenting with two new small and slow-
growing brain metastases. It is considered a standard of care and must be approved so that the enrollee can 
receive the treatment as soon as possible. The performance status of this enrollee is mainly dependent on a non-
oncology condition that does not affect the oncology outcome, prognosis, or treatment response. Brain SRS is 
particularly necessary given the results of recent computed tomography (CT) of the chest, abdomen, and pelvis, 
showing no new abnormal findings and no evidence of metastatic disease. Given the location and size of the 
lesions in the brain, the recommended therapy plan, dose, and type of radiation treatment are reasonable. Daily 
image-guided radiation treatment (IGRT) is medically necessary to ensure the safety and accuracy of radiation 
therapy delivery and treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SRS have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Radiosurgery (SRS) (77372, 77470).  
 
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: 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 due to the enrollee's state of chronic 
respiratory failure, severe lung disease with chronic carbon dioxide retention, and bilevel failure, it has been 
decided that the enrollee requires advanced ventilation, and simpler modes of ventilation are proven to be 
insufficient. 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 was admitted to hospital 
for COPD exacerbation from a respiratory syncytial virus (RSV) infection and required intubation for several 
days. The enrollee was extubated and trialed on BIPAP but did not tolerate it. The enrollee likely required 
intubation from RSV pneumonia and COPD exacerbation, however, this has been treated appropriately and 
resolved.  There is no indication that the enrollee cannot be placed on BIPAP and had attempted following 
extubation. A trial of BIPAP with average volume-assured pressure support (AVAPS) would be warranted and 
recommended prior to escalation to a home ventilator. This would be best and standard practice for this 
enrollee. Should the enrollee fail, a home ventilator would then be indicated, however, there is no signs of trial 
or failure as of yet. Hence, no indication for home ventilator, given data provided 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that radiation treatments were approved but IGRT is needed 
to make sure the cells are shrinking during the treatment process. The Plan denied your request. The Plan says 
there is not enough evidence that this type of radiation therapy guidance is needed or effective for your skin 
cancer. Therefore, it not considered standard of care. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you had a shave biopsy from the inferior cutaneous lip (left) on November 29, 2023, which 
confirmed invasive squamous cell carcinoma associated with squamous cell carcinoma. You have seen a 
provider with a plan for radiation treatment using superficial orthovoltage x-ray therapy. Your photo showing 
the lesion was reviewed. Due to limited available good quality data, the decision to use IGRT is still a clinical 
equipoise. Therefore, IGRT is not considered a medical necessity for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography and computed tomography 
(PETCT) scan (78815). 
 
You asked the Plan to pre-approve a PETCT scan. You say that the services are 
necessary.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PETCT scan. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the requested prostate-specific membrane 
antigen (PSMA) PET/CT is the best procedure of choice. 
 
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 PETCT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography and computed tomography (PETCT) scan (78815).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415-59-RT rendered on August 2, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 64415-59-RT (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that CPT 
64415 has a bundled relationship with CPT code 01630 which was also performed on August 2, 2023. The use 
of a modifier is allowed to unbundle this relationship, providing the medical documentation provided validates 
the use of an appropriate modifier. However, in this case the medical records provided does not include 
sufficient documentation to validate that CPT 64415 was performed a procedure that was distinct or 
independent from any other procedure performed, therefore the use of a 59 modifier is not appropriate. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 64415-59-RT rendered on August 2, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
October 23, 2023. 
 
You asked the Plan to pay for non-emergency ambulance transportation. You say that the enrollee was enrolled 
in hospice after returning home. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
October 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Revita skin substitute (Q4180). 
 
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 a review of the current medical literature shows that the evidence is insufficient and 
there remains an absence of randomized, blinded clinical studies examining benefit and long-term clinical 
outcomes establishing the value of this service in clinical management. 
 
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 this is medically necessary to facilitate healing of the wound dehiscence, amputation, and extensive 
surgical procedures. 
 
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 Revita skin substitute (Q4180).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for percutaneous image-guided neuromodulation 
or intravertebral procedures rendered on April 6, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says age related osteoporosis with current path fracture is not listed as a medically necessary 
diagnosis. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the coding submitted does not support the use of monitored anesthesia care. The enrollee had a T10 
vertebral body fracture and underwent a Kyphoplasty with Monitored anesthesia care. Therefore, the anesthesia 
service is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures 
rendered on April 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda 
 
You asked the Plan to pre-approve Keytruda. You say that this is the best treatment plan for the enrollee. The 
Plan denied your request. The Plan says the requested drug 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 Keytruda. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not FDA-
approved for the enrollee's diagnosis. The requested use of Keytruda is not supported by the drug compendia or 
in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that a MyoPro device is a powered orthosis 
designed to help restore function to arms and hands paralyzed or weakened. This device is medically necessary 
for the enrollee. The Plan denied your request. The Plan says there are not enough studies to show MyoPro is 
safe and effective to help the enrollee recover from his disability. Medicare does not cover experimental and 
investigational services. 
 
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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's stroke condition or in widespread use for this enrollee's condition based on scientific 
evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term 
outcomes for this enrollee. There is insufficient evidence in the literature that this device will increase 
participation in bimanual activities. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro device (L8702).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the aide services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the documentation does not support that the enrollee requires skilled nursing services or skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require skilled nursing or rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health aide services are not medically necessary as the enrollee does not have any skilled 
needs. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that initial coverage of home oxygen therapy and oxygen 
equipment is reasonable and necessary for beneficiaries in Group III, if all conditions 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 an oxygen concentrator. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not have 
hypoxemia and does not meet criteria for home portable oxygen therapy.  This is experimental therapy, hence, 
there is no indication for home oxygen. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.