Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant 360 testing (code 0242U) provided on July 1, 2022. 
 
You asked the Plan to pay for the testing. You say that all criteria for coverage are met. The Plan denied your 
request. The Plan says that there is no documentation indicating that there was genetic testing of the tumor or 
that sample and quantity were not sufficient, or that invasive biopsy was not possible. 
 
The Plan follows Medicare rules. Medicare rules say that this test is covered when the specific criteria are met, 
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 pay for the testing. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has not previously been tested with 
the Guardant360 test for the same primary cancer. The enrollee is untreated for the primary cancer being 
tested or is not responding to treatment. The enrollee has decided to seek further treatment. There is insufficient 
tissue for tissue-based CGP, and NCCN guidelines also recommend liquid biopsy with tissue.  
 
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 testing have been met. Therefore, we decided that the Plan has to pay for 
Guardant 360 testing (code 0242U) provided on July 1, 2022.  
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos. 
 
You asked the Plan to pre-approve Tymlos. You say that the enrollee has osteoarthritis and has already tried 
Risedronate. The Plan denied your request. The Plan says this medication falls under Part D coverage. 
 
  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 Tymlos.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. 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. 
 
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 the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve revascularization services. You say that the records provided support the 
need for the requested treatment. The Plan denied your request. The Plan says greater than 50% blockage in the 
arteries, other than the tibial artery, have not been confirmed. The Plan says that treatment is not supported for 
the tibial arteries for waking discomfort. The Plan says that there is no evidence that the enrollee has tried an 
exercise program to improve walking. The Plan says that there is no evidence of the enrollee having tried the 
medication cilostazol, which can also help improve walking distance. 
 
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 revascularization services. Our 
reviewer says that revascularization services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the treatment 
in question.  It is documented that the enrollee complains of leg cramping with swelling.  It is documented that 
the enrollee has shortness of breath with exertion and a positive stress test for which left heart catheterization is 
recommended.  The lower extremity Doppler study did not demonstrate any significantly elevated velocities throughout the lower extremity arteries bilaterally.  Ankle-Brachial Indexes (ABIs) appear to be artificially 
elevated likely due to diabetes, however no toe pressures are provided which could have provided helpful 
objective information.  As the enrollee has coexisting conditions for which treatment is being planned that may 
impede his activity/mobility along with absence of any sign of limb threat or objective evidence of significant 
arterial occlusive disease unable to overturn the Plan's determination on the basis of medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve Tramadol. You say that the enrollee cannot get out of bed due to pain. The 
Plan denied your request. The Plan says the requested drug is not a covered 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 Tramadol.  
 
Benefits for Tramadol 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: 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 you need IRF to be able to return home. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is currently in the hospital and is stable 
but is unable to go home. You say that the enrollee needs a lower level of care for more rehabilitation. You say 
that the enrollee is still dependent on all his cares and is still on a heat trach collar for respiratory support. The 
Plan denied your request. The Plan says the enrollee no longer needs daily nursing care. The Plan says that the 
enrollee does not require the intensity of therapy provided in a SNF.  
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 the enrollee does not have documented skilled nursing needs.  The enrollees 
tracheotomy is established, with no expectation of decannulation.  The enrollees feeding tube is established, 
with no expectation of removal.  The enrollee does not have documented skilled therapy needs.  The enrollee is 
dependent for mobility and activities of daily living (ADLs.)  Daily skilled services are not required to establish 
a maintenance program or to prevent deterioration of the enrollees condition.  The enrollees care needs are 
custodial and long-term, and 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (code 81529) provided on December 3, 
2021. 
 
You asked the Plan to pay for the testing. You say that this is a covered benefit. The Plan denied your request. 
The Plan says there were no medical notes included with this appeal to show the medical rationale for why the 
doctor ordered this test, why the number/type of genes tested, or how it will impact the member's treatment 
plan. 
 The Plan follows Medicare rules. Medicare rules say that this test is covered when the specific criteria are met, 
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 pay for the testing. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the enrollee does have a personal history 
of melanoma and has either stage T1b and above OR T1a with documented concern about adequacy of 
microstaging. However, it is unknown whether the enrollee is undergoing workup or being evaluated for 
treatment because there is no documentation of the rationale for the test. Further, it is unknown if the enrollee 
has metastatic disease. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing (code 81529) provided on December 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says your request for this spinal cord stimulator (SCS) trial is not medically necessary 
because the enrollee's neurosurgeon is concerned about the feasibility of implanting a permanent SCS, given 
the enrollee's super morbid obesity. The Plan states there is no documentation of recent physical therapy, and 
thus, it is not clear that this device would be a late or last option for treatment of the enrollee's pain. 
 
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 service. Our physician reviewer found the enrollee does not have an evidence-based indication for a spinal cord stimulator (SCS). The request 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical; decompression of 
subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed 
(CPT code 29826) and arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]) (29822). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has been waiting for surgery for 
several weeks. The Plan denied your request. The Plan says the enrollee's records do not show that they have 
tried at least six weeks of nonoperative therapy to include such treatments as anti-inflammatory medications or 
physical therapy. 
 
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 detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested arthroscopic shoulder decompression with debridement and partial 
acromioplasty (CPT 29826 and 29822), 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 arthroscopy, shoulder, surgical; decompression of subacromial space with partial 
acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (CPT code 29826) and 
arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral 
articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, 
articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign 
body[ies]) (29822).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulator (TENS) provided 
to the enrollee on May 23, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the information received does not support medical necessity. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has chronic low back pain. This is an excluded diagnosis. 
 
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 pay for a transcutaneous electrical nerve stimulator (TENS) provided to the enrollee on May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left breast implant removal (CPT code(s): 19328, 
19330, 19370 and 19371). 
 
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 services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has previously had cosmetic breast surgery. Removal of 
the right saline implant is scheduled due to painful contracture. The records provided do not indicate that the 
enrollee has left breast pain or a left contracture. The records indicate that simultaneous procedures are 
scheduled for cosmetic purposes. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left breast implant removal (CPT code(s): 19328, 19330, 19370 and 19371).
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. All medically necessary care is being provided in the current 
acute care setting. There are no services available at the LTACH that the enrollee requires that are not available 
at the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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: Favorable

 
We decided that the Plan has to pre-approve 20 fractions of Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve 20 fractions of IMRT. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 20 fractions of IMRT. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found IMRT with image-guided radiation therapy (IGRT) is medically reasonable as IMRT 
would be the standard approach in treating intact prostate, and 20 fractions of treatment follows from a 
randomized study using that same regimen and is supported by NCCN 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 20 fractions of IMRT have been met. Therefore, we decided that the Plan has to 
pre-approve 20 fractions of Intensity Modulated Radiation Therapy (IMRT).  
 
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.