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

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years. 
 
We looked at the file and Medicare rules. The file shows that your current PWC was purchased in 2020 and is not more than five years old and is not irreparably damaged.  Therefore, we decided that the Plan does not have 
to pre-approve a replacement power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service May 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and 
recommended for the patient. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed for date of service 
May 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox, 200 units every 12 weeks. 
 
You asked the Plan to pre-approve Botox. You say that this needs to be approved for the enrollee's condition. 
The Plan denied your request. The Plan says this is not a medically accepted indication for the requested drug. 
 
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 Botox. Our reviewer says that the 
requested use of Botox is not medically necessary. Our physician reviewer found the requested use of Botox is 
not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved 
journals). Therefore, the reviewer found that the requested use of Botox 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox, 200 units every 12 weeks.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve SI joint fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no SI joint instability, fracture, or lesion. SI joint fusion for degenerative back pain is 
experimental. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusion (27279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 12, 2023, billed with 
codes 87481, 87500, 87640, 87652 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this test was 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 12, 2023, billed with codes 87481, 87500, 87640, 87652 and 87798.
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 the enrollee meets the criteria for an 
LTACH appropriate admission. The Plan denied your request. The Plan says the LTACH admission criteria has 
been not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the enrollee's health Plan. The documentation does not support that LTACH services are medically 
appropriate 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to the LTACH is medically 
necessary. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee is currently not stable and requires additional short-term acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH would not be clinically advantageous and completion of treatment at the 
current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 the enrollee does meet LTACH 
admission criteria, and his ongoing medical care warrants an LTACH level of care. The Plan denied your 
request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 there are no services available at an LTACH that are not available in the current 
health care setting being offered by the enrollee's Health Plan. An LTACH admission 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BaroStim Neo system. 
 
You asked the Plan to pre-approve the BaroStim Neo. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the Barostim Neo system in 
the setting of congestive heart failure have not been demonstrated in the peer-reviewed literature. 
 
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 BaroStim Neo. Our reviewer says 
that the requested BaroStim Neo is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. Therefore, the reviewer 
found that the Barostim Neo system 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 the BaroStim Neo have not been met. Therefore, we decided that the Plan does 
not have to pre-approve BaroStim Neo system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nalu peripheral nervous stimulation (PNS) system and 
associated procedures (64555). 
 
You asked the Plan to pre-approve a Nalu PNS System and associated procedures. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Nalu PNS System and associated 
procedures. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the use of peripheral nerve stimulation for low back pain 
is experimental and is the subject of ongoing clinical trials. Therefore, the request 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 a Nalu PNS System and associated procedures have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Nalu peripheral nervous stimulation (PNS) system and 
associated procedures (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair.  
 
You asked the Plan to pre-approve a bath/shower chair. You say that the enrollee is having a total knee 
arthroplasty and will be confined to a single floor of her dwelling. The Plan denied your request. The Plan says 
this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 bath/shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pirfenidone. 
 
You asked the Plan to pre-approve pirfenidone. You say that the enrollee has been on this medication since 
2014 to slow the progression of their disease. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve pirfenidone.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by codes 77066 and G0279, 
performed on date of service January 26, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be covered 
because the enrollee did not have another insurance as primary on this date of service. The Plan denied your 
request. The Plan says the radiology services are denied because the enrollee had another insurance as primary 
on this date of service, and no explanation of benefits (EOB) from the primary insurer was received. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer on multiple occasions. As the secondary insurer, the Plan cannot 
be held responsible for the radiology services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the radiology services described by codes 77066 
and G0279, performed on date of service January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leg extensions for a walker, per set of four (E0158). 
 
You asked the Plan to pre-approve leg extensions for a walker. You say that your current walker is too short for 
you and creates strain on your hands and back because it is not tall enough for you. The Plan denied your 
request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that leg extensions are covered only for beneficiaries 
6 feet tall or more.  
 
We looked at the file and Medicare rules. Medicare rules confirm that leg extensions are covered only for 
beneficiaries 6 feet tall or more. The records show you are five feet nine inches; therefore, you do not meet 
criteria for approval of the leg extensions for your walker. Based on this information, we decided that Medicare 
rules for coverage of leg extensions for a walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve leg extensions for a walker, per set of four (E0158).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy, laminoplasty and thoracolumbar 
laminectomy for excision or occlusion of arteriovenous malformation of a spinal cord (63252, 63047, 69990, 
63051). 
 
You asked the Plan to pre-approve a laminectomy. You say that the request Is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee has any symptoms associated with 
lumbar spinal stenosis, signs or symptoms secondary to infectious process or tumor. 
 
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 laminectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a physical exam and imaging studies do not support the need for this surgery. It is not 
medically 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 a laminectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar laminectomy, laminoplasty and thoracolumbar laminectomy for excision or 
occlusion of arteriovenous malformation of a spinal cord (63252, 63047, 69990, 63051).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound-care supplies (A6196, A6212) provided from June 
23, 2022, to December 15, 2022. 
 
You asked the Plan to pay for wound-care supplies. You say that the items at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that supplies, appliances and equipment, which are 
ordinarily furnished by the hospital for the care and treatment of the beneficiary solely during the inpatient 
hospital stay, are covered inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wound-care supplies have not been met. Specifically, the case record indicates that on the dates of 
service at issue, the enrollee was a patient in a skilled nursing facility. The wound-care supplies at issue must 
be covered by the Medicare Part A benefit. 
  Therefore, we decided that the Plan does not have to pay for wound-care supplies (A6196, A6212) provided 
from June 23, 2022, to December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide.  
 
You asked the Plan to pre-approve a stair glide. You say that you have difficulty going up and down the stairs. 
The Plan denied your request. The Plan says stair glides and lifts are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) device. 
 
You asked the Plan to pre-approve the ILR device. You say that you do not agree with this denial. The Plan 
denied your request. The Plan says the records do not show that the enrollee has had strokes or fainting spells 
without a known cause. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a HolterTM monitor or a traditional pre-symptom 
MLR. 
 
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 ILR device. Our reviewer says that 
the requested ILR device is not medically necessary. Our physician reviewer found while the records indicate 
that the enrollee has a reported history of atrial fibrillation, there is no documentation provided to suggest a 
history of syncope, cryptogenic stroke or any other apparent indication for an ILR. Therefore, the reviewer 
found that the requested ILR device 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 ILR device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) device.