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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 12, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 99223 is not supported in the medical record because the 
records do not show a comprehensive examination. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; a 
comprehensive exam; and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported in the medical record. Our reviewer found the enrollee was a then, 84-year-old female with a history 
of coronary artery disease, congestive heart failure, paroxysmal atrial fibrillation, diabetes mellitus, 
hypertension, and hyperlipidemia who presented to the emergency room with chest pain. She was evaluated 
with a history and physical. lab studies, an EKG and chest x-ray. She was admitted with a diagnosis of acute on 
chronic congestive heart failure. The documentation indicates that code 99223 was not supported in the 
medical records because there was no comprehensive exam performed on the day of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found in this case you are not having a surgery that is on the "inpatient only" list. 
There is not a reasonable expectation that the care would need to span 2 or more midnights. The inpatient 
admission was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neurontin. 
 
You asked the Plan to pre-approve Neurontin. You say that the enrollee had side effects from the generic form. 
The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit. 
 
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 Neurontin.  Benefits for Neurontin 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve the requested services. You say that the device improves symptoms and 
quality of life. The Plan denied your request. The Plan says the device is considered unproven. 
 
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 requested services. Our physician 
reviewer found that there remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. At this time, the Barostim 
Neo system would not be considered medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combination use of Keytruda, Carboplatin, and 
Pemetrexed. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Pemetrexed. You say that the enrollee received 
prior chemotherapy/immunotherapy. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda, Carboplatin, and 
Pemetrexed. Our reviewer says that the enrollee does not meet criteria for this drug combination. Our physician reviewer found the requested combination is not Food & Drug Administration (FDA) approved for the 
enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve combination use of Keytruda, Carboplatin, and Pemetrexed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service June 15, 2022. 
 
You asked the Plan to pay for code 99223. You say that this code was supported by the medical record. The 
Plan denied your request. The Plan says code 99223 is not supported by the medical record because there was 
no decision making of high complexity. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these three key components: a comprehensive history; a 
comprehensive exam; and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the documentation for this date of service does not 
contain medical decision making of high complexity. The plan included continuing the current medications 
with some adjustments, physical and occupational therapy, and imaging. This is more consistent with medical 
decision making of moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's heart failure is 
progressively worsening. The Plan denied your request. The Plan says the device is unproven and 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 requested services. Our physician 
reviewer found that the enrollee has symptoms thought due to chronic systolic heart failure despite medical 
management, in the setting of severely reduced left ventricular function. There remains an absence of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim 
Neo in patient management. As a result, at this time the Barostim Neo system would not be considered 
medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda and gemcitabine. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the requested Keytruda and gemcitabine 
are not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis; however, the use is 
supported by clinical research that appears in a Medicare-approved medical journal. The documentation 
supports that the requested drugs are safe and effective and otherwise reasonable and medically necessary for 
the 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 been met. Therefore, we decided that the Plan has to pre-
approve Keytruda and gemcitabine.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service September 
15, 2022. 
 You asked the Plan to pay for procedure code 99497. The Plan denied your request. The Plan says payment for 
code 99497 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service September 15, 
2022.
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 the enrollee is not safe to return home. 
The enrollee lives alone, has impaired endurance and is very weak. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a long-term acute 
care hospital. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation. You say that the requested intracept 
intraosseous nerve ablation is medically necessary. The Plan denied your request. The Plan says the requested 
intracept intraosseous nerve ablation 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 intracept intraosseous nerve ablation. 
Our reviewer says that the requested intracept intraosseous nerve ablation is not considered medically 
reasonable and necessary. Our physician reviewer found that the intracept intraosseous nerve ablation is an 
experimental/investigational procedure. 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 intracept intraosseous nerve ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intracept intraosseous nerve ablation.
Appeal type: Step-Therapy
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 Durolane is the highest rated and longest lasting 
drug. The Plan denied your request. The Plan says the Plan requires a trial of Monovisc, Orthovisc, Synvisc, or 
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 criteria for a step therapy exception for Durolane. Our physician reviewer found you have not tried 
and failed the Plan's preferred drugs of Monovisc, Orthovisc, Synvisc, or 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a palliative dose and is not obviously 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the need for IMRT is not justified based upon quantifiable dosimetric measures or a plausible 
rationale. Policy models emphasize the need to support IMRT with dosimetry; this would be of particular 
important for clinical scenarios for which IMRT is not considered standard. As such, the requested IMRT 
would not be furnished in accordance with accepted standards of medical practice.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not list 
what drugs are to be tested. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order, lab requisition, or medical records showing the ordering physicians intent that the testing be performed. 
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 the drug testing services provided on March 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this due to worsening heart 
failure. The Plan denied your request. The Plan says the clinical value and effectiveness of CardioMEMS has 
not been demonstrated. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.