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

 
We decided that the Plan does not have to pre-approve Accu-Chek guide with device kit (CPT code E0607).  
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says you must try and fail all preferred blood glucose testing products that are covered by 
your Medicare Advantage plan. You may not have to try these products if your prescriber provides information 
that shows why the preferred products are not right for you. 
 
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 items. Our physician reviewer 
found the prescriber provided no additional information on the request form. You have not tried and failed any 
other diabetic testing supplies, and no medical reason you would not be able to use Plan's preferred products. 
The review has determined that the non-preferred product 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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Accu-Chek guide with device kit (CPT code E0607).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman procedure. 
 
You asked the Plan to pre-approve the Watchman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that devices FDA-approved 
indication and meet specific criteria. 
 
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 Watchman procedure. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the Watchman procedure at issue in this case meets all of Medicare's 
NCD criteria for medically reasonable and necessary for the enrollee. Provided records do not document that 
the enrollee has a CHA2DS2-VASc score = 3 as required by the NCD. 
 
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 Watchman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Watchman procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
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 Eylea. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Avastin before they will approve the requested drug. The requested drug is a new 
start. The provided records are inconsistent with respect to whether the enrollee has tried and failed the Plan's 
preferred step-one alternative and no primary source documents are provided to review. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred 
step-one 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Eylea (J0178).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent (alirocumab). 
 
You asked the Plan to pre-approve the Praluent. You say that it is felt that this treatment is necessary. The Plan 
denied your request. The Plan says this is a self-injected medication that is not covered by Medicare Part B. 
 
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 Praluent (alirocumab).  
 
Benefits for the Praluent 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 pre-approve laparoscopic radiofrequency ablation of the kidney. 
 
You asked the Plan to pre-approve laparoscopic radiofrequency ablation of the kidney. 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 laparoscopic radiofrequency ablation of 
the kidney. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested procedure for coverage, laparoscopic 
radiofrequency ablation of the kidney (CPT 50542) is not what the medical records show is actually planned. 
The records show that the planned procedure is computed tomography (CT) guided percutaneous microwave 
ablation of renal tumor (CPT 50592). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopic radiofrequency ablation of the kidney have not been met. 
Therefore, we decided that the Plan does not have to pre-approve laparoscopic radiofrequency ablation of the 
kidney.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and 
five days a week, or 15 hours over seven consecutive days. Currently, the enrollee is modified independent 
with lower body dressing and requires stand by assistance for toileting, transfers and ambulating short distances 
with a walker. The enrollee has had a functional decline from her baseline level of function and will likely 
benefit from therapy, but she does not require the intensity of therapies provided on acute inpatient 
rehabilitation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear device implantation (69930) of the right side 
and the formation of direct or tubed pedicle, with or without transfer; trunk of the right side (15770). 
 
You asked the Plan to pre-approve a cochlear device implantation (69930) of the right side and the formation 
of direct or tubed pedicle, with or without transfer; trunk of the right side (15770). You say that the enrollee 
suffered from idiopathic sudden sensorineural hearing loss in the right ear. You also say that the when the 
enrollee presented to your clinic, she had profound hearing loss in the right ear, with a complete inability to 
understand any words from the ear. The Plan denied your request. The Plan says this member has unilateral 
sensorineural hearing impairment. The Plan also says that they cannot say this cochlear implant is reasonable or 
necessary at this time. 
 
The Plan must follow Medicare rules. Medicare rules say (NCD) states that "cochlear implantation may be 
covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss.  
 
 
  We looked at the file and Medicare rules. The record shows that the enrollees hearing loss is unilateral. Based 
on this information, we decided that Medicare rules for coverage of a cochlear device implantation (69930) of 
the right side and the formation of direct or tubed pedicle, with or without transfer; trunk of the right side 
(15770) have not been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear device 
implantation (69930) of the right side and the formation of direct or tubed pedicle, with or without transfer; 
trunk of the right side (15770).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 cardiac event monitors are 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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 3, 2022, through 
April 29, 2022. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the admission 
date on the claim does not match the admission date on the NOA. 
  The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA should match the 
admission date on all subsequent claims.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the admission date on the claim does not 
match the admission date on the NOA submitted. Therefore, we decided that the Plan does not have to pay for 
home health services provided from April 3, 2022, through April 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Leqvio. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has unspecified hyperlipidemia. The documentation does not support that the enrollee has 
tried and failed Repatha. The documentation does not support that Repatha would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot bear weight on her leg. The Plan denied 
your request. The Plan says that the coverage criteria is no longer met. 
 
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 you do not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 
care. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76641, 77065 and G0279 provided on 
March 1, 2022. 
 
You asked the Plan to pay for procedure codes 76641, 77065 and G0279. The Plan denied your request. The 
Plan says procedure codes 76641, 77065 and G0279 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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. The CPT Code Manual definition of code 
77065 is diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral. 
The CPT Code Manual definition of code G0279 is diagnostic digital breast tomosynthesis, unilateral or 
bilateral (list separately in addition to 77065 or 77066).  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 procedure codes 76641, 77065 and G0279. Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the radiology report describes a limited unilateral breast ultrasound, and a complete ultrasound 
would be an inappropriate code to report for the service provided. The medical records also do not include 
documentation of a diagnostic mammography or a diagnostic digital breast tomosynthesis. Therefore, these 
procedures cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 76641, 77065 and G0279 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 76641, 77065 and G0279 provided on March 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS device is 
medically necessary due to the patient's worsening heart failure. The Plan denied your request. The Plan says 
this device is investigational and is therefore non-covered. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart failure 
(CHF) 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 CHF. 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 patients 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (denoxsumab) (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred drugs, 
intravenous pamidronate or zoledronic acid. 
 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 Xgeva. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (denoxsumab) (J0897).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 6 additional PT visits. You say that the enrollee needs additional PT for 
lower lumbar pain. The Plan denied your request. The Plan says 6 additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 6 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has chronic musculoskeletal pain. The 
enrollee needs a repetitive exercise program to address pain. The enrollee has normal range of motion. The 
enrollee has received extensive therapy program and is able to do a home exercise program. Continued unique 
input from a skilled therapist 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 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.