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

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the system will allow the enrollee 
to better monitor and manage those symptoms that lead to repeat heart failure hospitalization. The Plan denied 
your request. The Plan says the CardioMEMS device at this point should only be approved for enrollees 
enrolled in a clinical trial. There is no indication that this patient is enrolled in a clinical trial of the device. 
 
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 HF System. 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 enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee 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 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's 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 HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic back pain and 
lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee's pain is not relieved 
in flexion and imaging has not demonstrated moderate spinal stenosis. The Vertiflex spacer 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 a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve TheraSkin (Q4121). 
 
You asked the Plan to pre-approve TheraSkin. You say that the enrollee's wound is open and prone to infection. 
You say that you would like to keep the enrollee out of the operating room if possible. You also say that 
authorization was already approved in November for same procedure. The Plan denied your request. The Plan 
says that the requested procedure is not medically necessary. 
 
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 TheraSkin. Our reviewer says that the 
requested TheraSkin is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation indicates that based on the community standards of care, the requested 
service would be considered medically reasonable and necessary in order to avoid complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin have been met. Therefore, we decided that the Plan has to pre-
approve TheraSkin (Q4121).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an above the knee alignment system (L5920).  
You asked the Plan to pre-approve an above the knee alignment system. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare payment may be made for the replacement 
of prosthetic devices, which are artificial limbs, or for the replacement of any part of such devices, without 
regard to continuous use or useful lifetime restrictions if a treating practitioner determines that the replacement 
device, or replacement part of such a device, is 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 an above the knee alignment system. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found per A55426 as 
the provider addressed the socket but there is no evidence from the provider the alignment system is damaged. 
A prosthesis may be repaired and not replaced if cost does not exceed 60% of replacement cost. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an above the knee alignment system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an above the knee alignment system (L5920).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fulphila. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has pancytopenia from prior 
chemotherapy for diffuse large B-cell lymphoma (DLBCL). Fulphila is not approved by the Food and Drug 
Administration (FDA) for the enrollee's diagnosis; however, the use is supported by one of the major drug 
compendia or clinical research that appears in a Medicare-approved medical journal. The records support that 
Fulphila is safe and effective and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Fulphila.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after January 26, 
2023. 
 
You asked the Plan to pre-approve SNF care after January 26, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 after January 26, 2023. 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 daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 after January 26, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 25, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this service is not supported in the medical record. A different code is 
supported instead. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99223. Our reviewer says that code 99223 is 
not supported. Our reviewer found for this code, all three key components must be met or exceeded. In this 
case, code 99221 would be appropriate, as all three of these key components were not met for the reported 
code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 billed for date of service July 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avsola (Q5121). 
 
You asked the Plan to pre-approve Avsola. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Avsola. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Avsola. Our physician reviewer found the health plan 
requires that other forms of rheumatoid arthritis medications be tried first. There is no evidence that the 
enrollee is allergic to or intolerant of these other forms of medication. Our reviewer found that there is no 
evidence that the enrollee has tried and not responded to these other forms of medication. There is no 
documentation as to why these other forms of medication would not be expected to be safe and effective for the 
enrollee. Our physician reviewer also found that the requested Avosla is not shown to be currently medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avsola have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avsola (Q5121).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for fresh frozen plasma (P9059) billed for date of service August 27, 2022. 
 
You asked the Plan to pay for fresh frozen plasma. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met because the number of 
units billed exceeds the maximum allowed. 
 
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 rules also say that submitted claims in which the unit of service exceeds the MUE value cannot 
be paid when the MAI value is 3, unless there is evidence justifying the excess units. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial rationale states that you have billed a greater 
number of units than the maximum allowed. In this case, the MUE for CPT code P9059 is 15 when provided in 
a facility setting. You billed 3 units of this code. The record indicates the services at issue were provided in the 
emergency department of a hospital. We find that you have not exceeded the MUE for this code. 
 
The Plan has not provided any alternative rationales for denial. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for fresh frozen plasma (P9059) billed for date of service August 
27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external transmitter (A9277) and disposable sensor 
(A9276). 
 
You asked the Plan to pre-approve an external transmitter and disposable sensor. The Plan denied your request. 
The Plan says the details provided do not meet Medicare guidelines that show a medical reason the enrollee 
needs the purchase of a continuous glucose monitoring system (transmitter and 
sensors). The Plan also says that clinical information was not submitted to approve the request. 
 
The Plan must follow Medicare rules. Medicare rules say that products reviewed by the PDAC which do not 
meet the DME benefit category requirements must be coded as A9276, A9277, A9278, or A9279 and will be 
denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an external transmitter and disposable sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external transmitter (A9277) and disposable sensor (A9276).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5501 billed for date of service August 4, 
2022 to August 12, 2022. 
 
You asked the Plan to pay for procedure code S5501. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S5501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5501 billed for date of service August 4, 2022 to August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are met. 
 
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 you have pain in the sacral region of 
the spine. You had sacroiliac (SI) joint injections that provided excellent relief. The use of RFA to the lateral 
sacral branches is considered experimental due to wide variation in efficacy reported in the medical literature. 
The services are therefore 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 sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is 
experimental for low back pain. More research is needed to support its safety and efficacy. The services are 
therefore 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 an Intracept procedure.
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) with frequent exacerbations. An arterial blood gas (ABG) study in 
October of 2022, while acutely ill, was consistent with mild chronic carbon dioxide retention. The enrollee has 
not tried and failed the use of bi-level positive airway pressure (BiPAP) with average volume-assured pressure 
support (AVAPS). The home ventilator is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) with 
radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that there is a decreased risk of esophageal 
adenocarcinoma with ablation. The Plan denied your request. The Plan says the service is not considered 
medically necessary. 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. An EGD with radiofrequency ablation is considered not medically 
necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) with 
radiofrequency ablation.