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

 
We decided that the Plan has to pre-approve placement of a leadless pacemaker. 
 
You asked the Plan to pre-approve the leadless pacemaker procedure. You say that the enrollee meets all 
criteria for coverage of this procedure. The Plan denied your request. The Plan says that there is no evidence 
that the enrollee will be in a clinical trial/study. As such, this cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided clear documentation to prove that the enrollee cannot 
be enrolled in a prospective longitudinal study for the requested leadless pacemaker. There are two such studies 
NCT03039712 and NCT04235491. Both of these studies use Medicare claims data to track two populations, 
patients who received the leadless pacemaker and those who receive a standard pacemaker. Clinicaltrials.gov 
indicates the following for study NCT03039712: "The primary purpose of the study is to meet the CMS 
mandated Coverage with Evidence Development requirement in the National Coverage Determination for 
Leadless Pacemakers as they apply to Medtronic Micra devices." The Plan has simply indicated that the 
enrollee cannot participate with this study because it is listed as "active, not recruiting"; however, these studies 
review solely claims data and do not actively recruit participants, but rather they track subsequent claims 
information for the two populations. Without explicit documentation that this study will not be tracking the 
enrollee's data as it is set up to do, we find that the denial in this case is not supported. Therefore, we decided 
that the Plan has to pre-approve placement of a leadless pacemaker.  
 
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 Synvisc-One. 
 
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 the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. 
He has not tried and failed the Plan's required drugs, at least two of Euflexxa, Supartz FX, Durolane, or Gelsyn-
3. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Synvisc-One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura cream. 
 
You asked the Plan to pre-approve Opzelura cream. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the requested drug is self-administered and does not fall under 
Part B coverage. The Plan says that they do not administer Part D pharmacy benefits for the enrollee. 
 
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 Opzelura cream.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Neulasta. Our reviewer says that this 
drug is not medically necessary. Our physician reviewer found the records do not document that the 
chemotherapy regimen carries an intermediate or high risk of febrile neutropenia as is required for use of 
Neulasta. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta (J2506).
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 lives alone in a house with many stairs 
and is currently below her baseline and not independent. The enrollee is at risk for falling. The Plan denied 
your request. The Plan says the SNF care is not medically necessary. 
 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 there are no identifiable skilled nursing service needs. The record shows there are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services 
daily. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), x-ray exam 
of the lumbar spine (72100), manual therapy techniques (97140), mechanical traction therapy (97012), 
whirlpool therapy (97022), and the electrical stimulation (97032) rendered by the out-of-network (OON) 
provider from July 21, 2022, through July 29, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not payable as they 
were rendered by an out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941), x-ray exam of the lumbar spine 
(72100), manual therapy techniques (97140), mechanical traction therapy (97012), whirlpool therapy (97022), 
and the electrical stimulation (97032) rendered by the out-of-network (OON) provider from July 21, 2022, 
through July 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on July 19, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not know when you called that 
you would not be transported. The Plan denied your request. The Plan says that this service is not covered 
when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on July 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the Life2000 
system is not medically necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD).  
The Life2000 system is not a true ventilator because it is not capable of providing full ventilatory support. It is 
designed to provide positive pressure oxygen via nasal cannula during activity. There is inadequate evidence of benefit in the treatment of COPD. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance (eg, proton) imaging, spinal canal and 
contents, thoracic; without contrast material (72146). 
 
You asked the Plan to pre-approve a thoracic spine MRI. You say that you need the MRI. The Plan denied your 
request. The Plan says that there is insufficient information to show the enrollee meets criteria for an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a thoracic spine MRI. Our reviewer 
says that a thoracic spine MRI is medically necessary. Our physician reviewer found that extensive neurology 
notes have been submitted. Your complicated history as well as the increasing mid-back pain and the 
mechanical fall in 2021 provide adequate clinical information to go ahead with the requested MRI of the 
thoracic spine in order to rule out occult thoracic spine compression fracture and to evaluate the thoracic cord. 
An MRI is 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 a thoracic spine MRI have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast 
material (72146).  
 
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 Kimyrsa. 
 
You asked the Plan to pre-approve Kimyrsa. You say that this is being requested for acute osteomyelitis of the 
right metatarsal bone. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Kimyrsa. Our reviewer says that the 
requested use of Kimyrsa without culture results showing susceptible microorganisms or clinical 
documentation of strong suspicion of a covered microorganism is not supported. Our physician reviewer found 
that the provided records do not include any culture results showing the covered microorganisms.  
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kimyrsa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kimyrsa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone. 
 
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 self-administered drugs are not covered. 
 
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 dexamethasone.  
 
Benefits for these services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tablets. 
 
You asked the Plan to pre-approve Xarelto tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Xarelto tablets are not covered under the enrollee's 
Medicare 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 Xarelto tablets.  
 
Benefits for Xarelto tablets 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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-titration (AE), which could instead be provided by a BiPAP 
device with AVAPS and a back-up rate. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. The Plan denied your request. The Plan says this request is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that absent acute intervention, or a discrete change in 
otherwise stable clinical signs and symptoms, it is not medically necessary to repeat these examinations more 
frequently than annually. 
 
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 TTE. Our physician reviewer found 
the documentation would not point to a change in status that would support the medical necessity of a repeat 
TTE at this time. Our reviewer found that clinical guidelines do not support repeating a TTE following a 
previous TTE, with no intervening change in clinical status or new signs, symptoms or physical findings. Our 
physician reviewer also found that there is no supportive evidence for the medical necessity of repeat TTE 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on January 
31, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285. Our reviewer says 
that the medical records do not support the billing of code 99285. Our reviewer found the review indicates that 
the enrollee was with a history of diabetes who presented to the emergency department (ED) on January 31, 
2022, with complaints of chest pain, nausea and anorexia. She had fallen 1 week prior. On exam her physical 
exam was normal; chest radiograph was without evidence of rib fractures. Her diagnoses were hyponatremia, 
hypo-osmolality, and pleurodynia. She was discharged home later in the day. In this case, there was no medical 
decision making of high complexity. The review has determined the medical records did not support the billing 
of code 99285. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81599) provided on February 21, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered because it was provided OON and the enrollee 
was not referred by a 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 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 the lab services (81599) provided on February 21, 
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 the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).