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

 
We decided that the Plan does not have to pre-approve the Cala Trio therapy system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature does not consider this service to be standard 
medical treatment. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is insufficient evidence in the literature that this device is effective for the patient's tremor. The 
requested K1018 is not the standard of care for this enrollee's tremor according to current 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Cala Trio therapy system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299). 
 You asked the Plan to pre-approve additional home health skilled nursing visits. You say that you are 
extremely uncomfortable with the lesions on your body, and need assistance for wound care. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health skilled nursing 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found the wound is healing, and it is unclear how many additional skilled visits are necessary. The provider 
may request more visits based on progress. Our reviewer also found that the Pan approved 12 visits which are 
medically necessary, and criteria for additional visits not present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional home health skilled nursing visits (G0299).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be received in a different setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support that this enrollee requires skilled nursing 
services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and 
effectively provide care only in a SNF. The enrollee does not have complex wound care needs, enteral feedings 
or other skilled nursing needs that require a SNF admission. It is noted her IV antibiotics can be given by home 
health. The enrollee's functional level does not require the skills of a professional therapist only in a SNF. The 
enrollee does not require skilled nursing or skilled therapy on a daily basis. As a practical matter this enrollee's 
needs do not require the necessary services on an inpatient basis in a SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation provided indicates that the initial denial was appropriate. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
metastatic melanoma NRAS Q16R positive. The enrollee received several prior lines of immunotherapy with 
progression of disease. She has strokes which may be related to central nervous system (CNS) metastases. The requested use of Opdualag is not FDA-approved for the enrollee's diagnosis with progression on prior 
immunotherapy. This use is not supported by one of the major drug compendia, or by clinical research that 
appears 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the requested items are for a compounding pharmacy, rather than a requesting physician. Therefore, this service and medication 
cannot be considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home infusion therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve the drug. You say that this is the only way to treat the enrollee successfully. 
The Plan denied your request. The Plan says the drug is not requested for a medically-accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our physician reviewer found 
the record indicates that the enrollee has a diagnosis of pelvic floor myofascial pain. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The noted condition is not an enumerated one for which coverage is available under the rules. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Botox (J0585).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip replacement surgery. 
 
You asked the Plan to pre-approve the surgical service. You say that you are being denied surgery because of 
your smoking. You say that you have had two surgeries in the past four years with the recommendation against 
smoking that were not refused. You also say that you are willing to take the risk with this surgery as well. The 
Plan denied your request. The Plan says this 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 the surgical service. Our reviewer says 
that the requested hip replacement surgery is not considered medically reasonable and necessary in this case. 
Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. The documentation does not support any recent active physical therapy. Additionally, there are no objective exam findings provided to support right 
hip deficits. There are no diagnostic imaging studies provided to corroborate right hip pathology that would 
support the surgery that is being requested. Moreover, you continue to be a daily smoker with 
recommendations from the providers that you must complete smoking cessation prior to the surgery. Therefore, 
the requested total hip replacement is not medically reasonable or 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hip replacement surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845-80-59 rendered on April 10, 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 22845-80-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22845 is "Anterior instrumentation; 2 to 3 vertebral 
segments (List separately in addition to code for primary procedure)."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services Our 
reviewer found that CPT 22845 is not supported as separate from CPT 22853 and cannot be unbundled. It 
cannot be approved as a separate code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 22845-80-59 rendered on April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44680 and 49020 rendered on December 23, 
2022. 
 
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 the denied codes are not supported in the records submitted. 
 
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 in 
terms of CPT 44680, the provider reported intestinal plication for service provided, however operative report 
does not support procedure. For CPT 44680, the provider arranges loops of intestine in folds, and sutures the folds together to prevent them from unfolding. This procedure is performed to prevent fistual formation, 
adhesions, or kinking of bowel. This procedure was not found documented in the operative report and therefore 
cannot be verified. 
 
In terms of CPT 49020, the provider reported the procedure code with appended modifier 59 distinct 
procedural service to bypass the edit with the partial colectomy. The operative report describes drainage of 
peritoneal abscess near sigmoid colon; however, a more comprehensive procedure was performed, same 
anatomical area, therefore separate billing is not supported. 
 
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 codes 44680 and 49020 rendered on December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthosis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that 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 
patient's condition or in widespread use for this patient'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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro orthosis.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not require services that can only be provided as an inpatient in a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is 
functioning below her baseline. The records do not establish that the enrollee has reached a new, lower, level of 
function. Daily skilled services are required to return the enrollee to her prior level of function, establish a 
maintenance program and/or prevent deterioration of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. 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 total knee arthroplasty is covered when specific 
criteria 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 a total knee arthroplasty. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found detailed documentation is not 
evident regarding pain or functional disability attributable to the advanced joint disease. There are no recent 
examinations provided for review to corroborate ongoing right knee pain and or deficits. Moreover, detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for teeth #23, 26 (D2752). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 18, 2019. 
Therefore, we decided that the Plan does not have to pre-approve crowns for teeth #23, 26 (D2752).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization of the lower extremity 
and a catheter-based angiogram. 
 
You asked the Plan to pre-approve percutaneous revascularization of the lower extremity and a catheter-based 
angiogram. You say that the requested percutaneous revascularization of the lower extremity and catheter-
based angiogram are medically necessary. The Plan denied your request. The Plan says the requested 
percutaneous revascularization of the lower extremity and catheter-based angiogram are 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 percutaneous revascularization of the 
lower extremity and a catheter-based angiogram. Our reviewer says that the requested percutaneous 
revascularization of the lower extremity and catheter-based angiogram are not medically necessary. Our 
physician reviewer found the documentation does not support the medical necessity of the treatment in 
question. Much of the documentation provided relates to findings and a procedure the enrollee had in early 
2023. There is no documentation of a recent history and physical examination provided. There is no description 
of the nature of the enrollees symptoms, no pulse examination, no ankle-brachial index (ABI) results provided, 
and no assessment and plan describing an evaluation of the risks and benefits and rationale for proceeding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization of the lower extremity and a catheter-based 
angiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
revascularization of the lower extremity and a catheter-based angiogram.