Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for vertebrogenic low back pain. She presented with scoliosis of the 
lumbar spine. There is pain that is in the thoracic and lumbar spine, bilaterally, midline, and deep. The exam 
revealed a mild forward list and scoliosis. Dyskinesis of the lumbar spine motion is seen. Pain increased with 
forward flexion of the back. Pain increased with hyperextension and thrust. Deep tendon reflexes are 
diminished at the knee and ankle. Strength and sensation are full. 
 In this case, there were/are multiple plausible pathologic sources of significant pain generation. The lumbar 
spine pain that is bilateral, midline, and deep, the noted pain-aggravating factors (standing, walking, lifting, 
carrying, twisting, going from sit to stand, cold weather, and damp weather), pain-relieving factors (heat, 
exercise, stretching, therapy, and cortisone injection), along with the dyskinesis of the lumbar spine motion 
were/are all non-specific to multiple pathologic entities. 
 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. The documentation does not support actual formal surgical ablation of pre-designated basivertebral 
nerves as being medically necessary and/or reasonable. 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 L3, L4, L5, and S1 vertebrae, 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a loop recorder implant procedure. 
 
You asked the Plan to pre-approve a loop recorder implant procedure. You say that a loop recorder implant 
procedure is medically necessary. The Plan denied your request. The Plan says a loop recorder implant 
procedure is not medically necessary and does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 loop recorder implant procedure. Our 
reviewer says that the requested loop recorder implant procedure is not medically necessary. Our physician 
reviewer found that the symptom of chronic palpitation with no history of syncope, normal LV systolic 
function by echo, and previously tested cardiac monitoring and cardiopulmonary stress test with unremarkable 
findings does not meet the criteria for implantable heart rate/rhythm monitoring 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 a loop recorder implant procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a loop recorder implant procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on 
October 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the facility is responsible for 
obtaining authorization. The Plan denied your request. The Plan says the provider is out-of-network and there 
was no authorization for the services. 
 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 subsequent nursing facility care (99308) provided 
on October 22, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve The Coflex device (22867). 
 
You asked the Plan to pre-approve The Coflex device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve The Coflex device. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception to guidelines. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve The Coflex device (22867).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. 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 Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of exudative age-related macular degeneration, left eye. The documentation 
does not support that the enrollee has tried and failed bevacizumab. The documentation does not support that 
bevacizumab 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy (29881). 
 
You asked the Plan to pre-approve a knee arthroscopy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 knee arthroscopy. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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.  The MRI demonstrated moderate-
severe degenerative changes of the medial compartment joint space, and mild-to-moderate degenerative 
articular changes patellar facets. The peer-reviewed literature does not typically support arthroscopic lavage 
and debridement (or meniscectomies) in the presence of such degenerative changes. 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 a knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroscopy (29881).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertiflex device placement surgery (22869). 
 
You asked the Plan to pre-approve a vertiflex device placement surgery. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is considered 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 vertiflex device placement surgery. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered 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 vertiflex device placement surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a vertiflex device placement surgery (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dayspring Active compression system and garment. 
 
You asked the Plan to pre-approve a Dayspring Active compression system and garment. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items are 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 Dayspring Active compression 
system and garment. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the peer-reviewed medical literature does not document 
equivalence or superiority of the requested nonpneumatic compression device over standard pneumatic 
compression treatment for lymphedema. 
 
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 Dayspring Active compression system and garment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dayspring Active compression system and 
garment.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 18, 2020, 
to October 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claims for home health episodes may be submitted 
prior to the 60th day if the beneficiary has been discharged and treatment goals have been met. 
 
We looked at the file and Medicare rules. The file shows that there was not a 60 day gap in home health services prior to the dates of service at issue. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
home health services rendered from September 18, 2020, to October 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on 
September 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee did not have a choice 
in providers. The Plan denied your request. The Plan says the provider is out-of-network and there was no 
authorization for the services. 
 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 subsequent nursing facility care (99308) provided 
on September 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for Intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational as 
there are not enough studies on Intracept to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga (J8499). 
 
You asked the Plan to pre-approve Farxiga. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says Farxiga is not eligible for coverage under the Part B medical 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 Farxiga (J8499).  
 
Benefits for Farxiga may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wound cleanser (A6260). 
 
You asked the Plan to pre-approve wound cleanser. You say that you have a major cut in your leg. You also 
say that you need this service. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wound cleansers are non-covered under the 
surgical dressing benefit because they do not meet the statutory definition of a dressing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wound cleanser have not been met. Therefore, we decided that the Plan does not have to pre-
approve a wound cleanser (A6260).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the medical 
record does not document a clearly evident need for the services of a skilled physical therapist. The enrollee 
has already been educated on a home exercise program. There is no documentation of an active or acute on 
chronic condition that would necessitate a new program. There is no documentation of a recent change in the 
treatment plan. There is no documentation of a recent face-to-face evaluation from the enrollees 
physician/provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev (Q5118), Flourouracil (J9190), Leucovorin 
Calcium (J0640), Irinotecan (J9206), and Dexamethasone (J1100). 
 You asked the Plan to pre-approve Zirabev, Flourouracil, Leucovorin Calcium, Irinotecan, and 
Dexamethasone. You say that this service is medically necessary. The Plan denied your request. The Plan says 
Original Medicare covers this service. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Zirabev, Flourouracil, Leucovorin Calcium, Irinotecan, and 
Dexamethasone as part of a clinical trial. The Plan does not cover routine costs associated with qualifying 
clinical trials. Therefore, we decided that the Plan does not have to pre-approve Zirabev (Q5118), Flourouracil 
(J9190), Leucovorin Calcium (J0640), Irinotecan (J9206), and Dexamethasone (J1100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral (0627T). 
 
You asked the Plan to pre-approve the back procedure. You say that the denial for this procedure is 
unwarranted and unsupported by the enrollee's current medical status and is inconsistent with currently 
accepted medical practice. The Plan denied your request. The Plan says the requested injection of allograft 
(e.g., VIA Disc Matrix) into the intervertebral disc for the treatment of degenerative disc disease is considered 
experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the back procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral (0627T).