Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of chronic 
low back pain have not been demonstrated in the peer-reviewed literature. The Plan states more research is 
needed to show safety and efficacy of the procedure. 
 
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 services. 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. Therefore, the requested intracept intraosseous basivertebral 
nerve ablation at L5 and S1, 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for colonoscopy. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 colonoscopy provided on April 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar-sacral orthosis to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve lumbar-sacral orthosis. You say that it is medically necessary for the 
enrollee to receive the lumbar-sacral orthosis. The Plan denied your request. The Plan says they are not 
contesting the medically necessity. The Plan is saying that the service can be provided by 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lumbar-sacral orthosis to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc procedure (0627T, 0628T). 
 
You asked the Plan to pre-approve a Via Disc procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental. 
 
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 Via Disc procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Via Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Via Disc procedure (0627T, 0628T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the 
sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and 
interpretation, and pulmonary artery angiography, when performed (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the CardioMEMS device is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
coverage. Therefore, the request 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 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 the CardioMEMS device was approved by the 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 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for 
long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart 
catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary 
artery angiography, when performed (33289).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the PBRT (CPT code(s): 77387, 77525 and G6002). 
 
You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of proton beam therapy (PBT) compared with 
intensity-modulated radiation therapy (IMRT) in the setting of Stage III non-small-cell lung carcinoma 
(NSCLC) has not been demonstrated in the peer-reviewed literature. 
 
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 pre-approve the PBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy would be furnished in accordance with accepted standards. 
 
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 PBRT have been met. Therefore, we decided that the Plan has to pre-
approve the PBRT (CPT code(s): 77387, 77525 and G6002).  
 
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 pre-approve an office visit with neuropathy treatment to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that there are no in-network providers available that 
provide the medical services you need. The Plan denied your request. The Plan says that the requested provider 
is an OON provider and there are multiple in-network providers available in the enrollee's service area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with neuropathy treatment to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for inpatient hospital services provided on 
April 17, 2021, through May 15, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the services and 
supplies at issue are considered routine or not supported by the medical records.  
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, all of the items that have been 
denied by the Plan with a status code of G are considered routine items and services. Payment for these 
supplies and services is included in the room and board charge. Additionally, the supplies and services that 
have been denied by the Plan with the status code of K are not supported by the records submitted. Therefore, 
we decided that the Plan does not have to pay an additional amount for inpatient hospital services provided on 
April 17, 2021, through May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power-operated scooter. 
 
You asked the Plan to pre-approve a power-operated scooter. You say that this device is medically necessary 
for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power-operated scooter.
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 enrollee meets criteria for IRF care. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for IRF care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo 6MG/0.05ML solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee does not have any stated contraindications to the preferred products, 
the enrollee has not tried any of the preferred agents and the provider does not provide a rationale for use of the 
non-preferred product for safety or efficacy. 
 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 the medication. 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. The elements of the coverage criteria are not satisfied. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vabysmo 6MG/0.05ML solution.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
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 that recovery from a pelvic fracture requires ambulation as tolerated.  
 The necessary rehabilitation services are not complex, do not require physiatry oversight and are available at a 
variety of levels of care and do not require an IRF admission. Criteria is not met. Your pain is well managed 
and you are medically stable. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Intradialytic Parental Therapy (IPT) (B4185, B4193, B4197, 
B4189). 
 
You asked the Plan to pre-approve IPT. You say that the requested is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says that the enrollee does not meet coverage criteria for the 
requested service. 
 
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 pre-approve IPT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has had dietician counseling and has been getting oral supplements and still has 
severe nutritional deficit. IPN is approved due to severity of malnutrition and failure of standard means of 
correction. The request is medically indicated and will help 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 IPT have been met. Therefore, we decided that the Plan has to pre-approve 
Intradialytic Parental Therapy (IPT) (B4185, B4193, B4197, B4189).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that if you are not admitted you will lose your mobility 
and this is affecting your mental health as well. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (CPT code J3245). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): Remicade, 
Inflectra OR infliximab, and Stelara. The Plan states there is no indication the Plan's preferred drug(s) would 
likely be: less effective, and/or cause adverse effects for the enrollee. 
 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 the medication. 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. The elements of the coverage criteria are not satisfied. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya (CPT code J3245).