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

 
We decided that the Plan does not have to pre-approve smart drive (E0988) and free wheel (K0108) features 
for a manual wheelchair. 
 
You asked the Plan to pre-approve the manual wheelchair accessories. You say that the features are medically 
necessary. The Plan denied your request. The Plan says these features are for use outside the home and non-
covered. The record shows the enrollee does not use a wheelchair in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve smart drive (E0988) and free wheel (K0108) features for a manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this will improve your quality of life and help ease 
pain. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because 
the Plan requires a trial of Orthovisc, Synvisc, and Synvisc-One before it will approve Durolane. 
 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 Durolane. Our reviewer says that you 
do not meet the Medicare criteria for a step therapy exception for Durolane. Our physician reviewer found you 
have not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, and Synvisc-One. The record does 
not show that these drugs would likely be less effective and/or have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Durolane.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right total knee arthroscopy. 
 
You asked the Plan to pre-approve right total knee arthroscopy. You say that this procedure is medically 
necessary because the patient has failed prior conservative treatment. The Plan denied your request. The Plan 
says this procedure 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 right total knee arthroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this patient was being treated for complex tear of the medial meniscus of the 
right knee. He presented with right knee pain. He is having a difficult time standing and walking. The pain is 
1/10 at best and 8/10 at most. There is pain with weight bearing. There is popping and catching in the right 
knee. He notes catching, locking, and swelling. The exam reveals an antalgic gait. There is a small effusion in 
the right knee. There is maximal tenderness at the medial knee. X-rays of the right knee are noted to show more 
mild osteoarthritic change with Kellgren-Lawrence stage II. 
 However, there is limited published, large-scale, long-term peer-reviewed literature that shows this request to 
be an effective and/or safe treatment for the noted pathology. Knee arthroscopy is not supported with findings 
of osteoarthritis in the surgical knee. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right total knee arthroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right total knee arthroscopy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1/2 complete genetic analysis. 
 
You asked the Plan to pre-approve the BRCA genetic analysis. You say that this is medically necessary testing. 
The Plan denied your request. The Plan says the results of this testing are not likely to change management of 
the patient. 
 
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 BRCA genetic analysis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is an 83-year-old man with a history of prostate cancer treated 
with prostatectomy and kidney cancer. It is documented that the enrollee has evidence of recurrent malignancy, 
and that his prostate-specific antigen (PSA) is rising. The clinical documentation does not support that the 
requested testing would impact the management and outcome of the enrollee in this case, and that the testing 
meets, but does not exceed, the enrollee's medical need, and is at least as beneficial as an existing and available 
medically appropriate alternative. 
  
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 BRCA genetic analysis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve BRCA 1/2 complete genetic analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair with power features 
(K0861, E2361, E1028, E2377). 
 
You asked the Plan to pre-approve the replacement power wheelchair with power features. You say that the 
new power wheelchair with power features is medically necessary. The Plan denied your request. The Plan 
says the enrollee has already been issued a power wheelchair within the last 5 years. The new power 
wheelchair is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair that was issued October 10, 2020. [current item enrollee is 
using] serves the same purpose as the replacement power wheelchair with power features. The record does not 
show that the current wheelchair is damaged or more than 5 years old.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair with power 
features (K0861, E2361, E1028, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
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 enrollee has low back pain 
secondary to sacrococcygeal disorder. There is insufficient literature to support that SI joint RFA is safe and 
efficacious for the enrollee's specific clinical condition. The services are considered investigational in nature 
and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the enrollee has severe debility from acute illness and functional decline, but 
does not meet coverage criteria for this admission. The enrollee is medically stable and does not need physician 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. No acute rehab nursing needs identified or documented in the record. At the 
current functional level, with inability to tolerate therapeutic activity, the enrollee does not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. The enrollee will not be able to tolerate the intensity of IRF therapies. RF admission is not 
medically necessary based on acute rehab nursing needs and inability to endure the intensity of IRF therapies. 
The enrollee's rehab needs can be met safely and provided at a lower intensity and alternate setting such as in a 
skilled nursing facility. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically reasonable and necessary. The Plan 
denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Retacrit (Q5106).  
 
Benefits for Retacrit 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 4, 
2021. 
 
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 this was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 33880, 34713, 75956 is 1. The MAI value for this code is 2. You billed 2 
units of this code, exceeding the MUE. 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 surgical 
services provided to the enrollee on November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan services (78816) 
 
You asked the Plan to pre-approve PET scan with CT scan services. You say that this imaging service is 
medically reasonable and necessary. The Plan denied your request. The Plan says the requested imaging is not 
medically necessary. 
 
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 PET scan with CT scan services. Our 
reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer 
found that the review indicates that the enrollee has progressive dysphagia. There is no specific clinical 
rationale for a PET scan. The review has determined that the member does not have an indication for which a 
PET Scan can be covered 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 PET scan with CT scan services have not been met.  Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) scan 
with concurrently acquired computed tomography (CT) scan services (78816)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accessories and features for a power wheelchair. 
 
You asked the Plan to pre-approve accessories and features for a power wheelchair. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. The rules also say 
that, if the PWC base is not covered, then related accessories will be denied. 
 
 We looked at the file and Medicare rules. In this case, you are requesting accessories and features for a power 
wheelchair which would serve as a replacement for a power wheelchair received by the enrollee on October 10, 
2020. The replacement in question is for an item that has not outlasted its reasonable useful lifetime and 
therefore cannot be covered. Based on this information, we decided that Medicare rules for coverage of 
accessories and features for a noncovered PWC base have not been met. Therefore, we decided that the Plan 
does not have to pre-approve accessories and features for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this item is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested item is considered 
experimental/investigational at this time. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart failure in 
this patient. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure. The clinical study on which FDA approval was 
based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patient's 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 20, 
2021. 
 
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 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on June 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
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 the enrollee has age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's required drugs, zoledronic 
acid, teriparatide, denosumab, or abaloparatide. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Evenity 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 Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and related accessories. 
 
You asked the Plan to pre-approve a power wheelchair and related accessories. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair and related accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc injection services. 
 
You asked the Plan to pre-approve Orthovisc injection services. You say that the enrollee has been under his 
care for left knee osteoarthritis and has undergone viscosupplementation on December 13, 2021. You say that 
this helped the enrollee tremendously. You say that the relief lasted just about 5 months and repeating 
viscosupplementation is needed to avoid scheduling a left total knee arthroplasty. The Plan denied your request. 
The Plan says the requirements for approval have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an injection or course of the injections will not be 
repeated within six months time. 
 
  
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 Orthovisc injection services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found it has not been six 
months since the last visco-supplementation injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Orthovisc injection services.