Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the WATS-3D laboratory services (88361, 88312, 88305, 88112) 
provided November 29, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that your gastrointestinal pathologist performed 
analysis of the tissue specimen and a complete pathology report was issued to the ordering physician. The Plan 
denied your request. The Plan says that the information needed to consider this charge was not provided. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of Barrett's esophagus without dysplasia. A histocytology report in 
December 2021 states, "Columnar epithelium is present". In patients with known or suspected Barrett's 
esophagus, the use of WATS-3D in addition to white light endoscopy 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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the WATS-3D laboratory services (88361, 88312, 88305, 88112) provided November 29, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that intravenous (IV) iron therapy 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has iron deficiency 
anemia. The records indicate a hemoglobin of 14.5 mg/dl with normal corpuscular indices. The enrollee is 
receiving oral iron. There is no documentation of chronic kidney disease. The Food and Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2000 system (E0466). 
 
You asked the Plan to pre-approve the system. You say that the Life2000 system is necessary. The Plan denied 
your request. The Plan says the Life2000 system is not necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the system. Our physician reviewer 
found the Life2000 system is not a true ventilator, because it is not capable of providing full ventilatory 
support. There is inadequate evidence of the safety and efficacy of this device in the treatment of patients 
recovering from chest trauma. 
 
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 Life2000 system (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure-reducing mattress (E0277). 
 You asked the Plan to pre-approve a pressure-reducing mattress. You say that the enrollee is not able to move 
themself. You also say that the enrollee is unable to sit or be moved around the facility due to the lack of a 
wheelchair of sufficient size. The Plan denied your request. The Plan says the enrollee does not have pressure 
ulcers at this time. The Plan also says the requested mattress is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface may be covered if certain 
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 pressure-reducing mattress. Our 
reviewer says that the requested pressure-reducing mattress is not medically necessary. Our physician reviewer 
found the enrollee is currently living in a residential care facility and requires re-positioning while in bed as 
well as a Hoyer lift for transfers. The most recent clinical documentation does not indicate that the enrollee has 
skin breakdown or pressure wounds. Documentation in terms of a telephone encounter notes that the enrollee 
now has bed sores but there is no clinical documentation regarding this as well as the location and staging of 
potential pressure wounds. Therefore, the reviewer found that the requested pressure reducing mattress 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 a pressure-reducing mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pressure-reducing mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial endosteal implant (21248). 
 
You asked the Plan to pay for the partial endosteal implant. You say that the service was medically necessary. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 pay for the partial 
endosteal implant (21248).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left total knee arthroplasty. 
 
You asked the Plan to pre-approve the knee procedure. 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 knee procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures to include a formal course of physical therapy. The 
enrollee has only attended one session of therapy as of March 8, 2023. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested left total knee arthroplasty, in this case, 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 knee procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve left total knee arthroplasty.
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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee as age-related 
osteoporosis without osteoporotic fracture. He has not tried and failed the Plan's required drug, zoledronic acid. 
The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is 
not reasonable or 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 these services 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 the Coflex lumbar interspinous decompression device 
(22867). 
 
You asked the Plan to pre-approve the device. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the Coflex lumbar interspinous decompression device is unproven and not 
medically necessary 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 device. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested Coflex lumbar interspinous decompression device at L4-5, in this case, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex lumbar interspinous decompression device (22867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. 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 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 the 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve Synthroid tablets. You say that Synthroid tablets are medically necessary 
and reasonable for the enrollee's medical condition. The Plan denied your request. The Plan says Synthroid is a 
self-administered drug, and does not fall under 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 Synthroid tablets.  
 
Benefits for Synthroid tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine additional months of intradialytic parenteral 
nutrition (IDPN). 
 You asked the Plan to pre-approve the additional months. You say that this is a safe, effective, and less costly 
intermediate treatment to bridge the gap between first line treatments. The Plan denied your request. The Plan 
says the enrollee can have approval of a partial consecutive three-month trial of IDPN. 
 
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 additional months. Our reviewer 
says that the requested additional months are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the remaining months can be allowed if there is new clinical objective 
documentation is submitted with appropriate reassessment by a registered dietician. There needs to be repeat 
laboratory results showing a clinical response to this request before additional services can be approved. The 
review has determined that there is no documentation provided indicating that the enrollee needs more than 3 
months of the requested IDPN. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine additional months of intradialytic parenteral nutrition (IDPN).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal mechanical thrombectomy 
(37184) and aortography (75625) provided on July 26, 2022. 
 
You asked the Plan to pay for the percutaneous transluminal mechanical thrombectomy (37184) and 
aortography (75625). You say that the procedure codes were billed correctly with modifiers, which support 
separate payment for these charges. The Plan denied your request. The Plan says procedure codes 37184 and 
75625 are not supported by the medical records submitted. 
 
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 37184 is primary percutaneous transluminal mechanical 
thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance 
and intraprocedural pharmacological thrombolytic injection(s); initial vessel. The CPT Code Manual definition 
of code 75625 is aortography, abdominal, by serialography, radiological supervision and interpretation. 
 
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 percutaneous transluminal mechanical thrombectomy 
(37184) and aortography (75625). Our reviewer says that the documentation submitted was reviewed and does 
not meet the criteria for coverage. Our reviewer found that the procedure report does not include enough 
documentation to confirm a primary percutaneous transluminal mechanical thrombectomy was performed. The 
procedure report also does not describe an abdominal aortography. 
 
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 percutaneous transluminal mechanical thrombectomy (37184) and 
aortography (75625) have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous transluminal mechanical thrombectomy (37184) and aortography (75625) provided on July 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on August 8, 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 assistant surgeon services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) codes 92937, 92979, 92978, and 93459. The Medicare Fee Schedule Database contains a 
surgical indicator of 0 for these procedures.  
 
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 these services. Our reviewer says that the 
assistant surgeon services were not medically necessary. Our physician reviewer found the documentation 
reveals complex coronary anatomy and a challenging percutaneous coronary intervention (CC-PCI) procedure; 
however, the rationale for an assistant surgeon rather than a cardiovascular technologist is not clear. As such, 
the use of an assistant surgeon in carrying this enrollee's CC-PCI was not medically necessary in the 
management of this 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the assistant surgeon services rendered on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says these services can be provided from an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in 
this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require 
the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on November 29, 2022, by an out-of-network (OON) provider.