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

 
We decided that the Plan has to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says that the requested Euflexxa is not medically necessary. 
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of osteoarthritis of the knees. The record indicates that the enrollee has failed simple analgesics 
and physical therapy. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. The elements of the coverage criteria are satisfied.  The requested service is 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve 
Euflexxa.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that the services are necessary. The 
Plan denied your request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have 
to pre-approve quantitative calcium scoring (75571).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the requested Euflexxa is not medically necessary. 
 
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 Euflexxa. Our reviewer says that the 
requested Euflexxa is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of osteoarthritis of the ankle. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says that the hospital is asking for the enrollee to be inpatient from 
March 23, 2023, to March 26, 2023. The Plan states the enrollee had low blood sugars. The Plan states the 
enrollee got better quickly after being treated in the emergency room, the enrollee's blood sugars have 
improved and the doctor noted the enrollee wase stable on March 26, 2023, and waiting to see the enrollee's 
primary doctor on March 27, 2023. The Plan states the enrollee needed to be in the hospital but could have 
been treated as an observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the record shows that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block (64454). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested genicular radiofrequency ablation is deemed investigational or 
experimental. The Plan states a treatment is considered investigational or experimental when it has progressed 
to limited human application but has not achieved recognition as being proven effective in clinical medicine. 
 
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of genicular nerve block in post-operative patients is the subject of ongoing clinical 
trials and is considered experimental at this time. Therefore, the request is deemed not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the genicular nerve block (64454).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for review by radiologist of abdominal artery image (75726) and 
review by radiologist of additional artery image (75774) provided on August 08, 2022. 
 You asked the Plan to pay for the x-rays. You say that the claim should be paid as billed The Plan denied your 
request. The Plan says review by radiologist of abdominal artery image (75726) and review by radiologist of 
additional artery image (75774) remains not supported. 
 
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, we have confirmed that code 37244 is a column II code to column I code 75726 and 75774; 
however, 37244 was billed with a modifier.  
 
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 the x-rays. Our reviewer says that the documentation does 
not support procedure codes 75726 and 75774.  Our reviewer found that the procedure report does not provide 
clear documentation to support the review by the radiologist of abdominal artery image and review by the 
radiologist of additional artery image billed was provided. In terms of CPT 75726, the record does not contain 
evidence that a review by radiologist of abdominal artery image was performed. This procedure is considered 
inclusive to procedure code 37244; therefore, the code cannot be verified. In terms of CPT 75774, the record 
does not contain evidence that a review by radiologist of additional artery image was performed. This 
procedure is considered inclusive to procedure code 37244; therefore, the code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have 
to pay for review by radiologist of abdominal artery image (75726) and review by radiologist of additional 
artery image (75774) provided on August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service August 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records show medical necessity. The 
Plan denied your request. The Plan says an inappropriate diagnosis was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We find that CPT code 93971 was billed with diagnosis code M79.605, pain in left leg. The medical records 
indicate the procedure at issue was performed on the right leg. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 93971 billed for date of service August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that further delay in transferring to long term 
care will directly jeopardize the enrollee's ability to fully recover and successfully regain maximum 
independence. The Plan denied your request. The Plan says the request is not medically necessary, and the 
enrollee can safely receive this care in another setting. 
 
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 is improving but is not yet stable for transfer. The enrollee should only 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
they are more stable for a lower level of care. Completion of treatment at the current facility is recommended. 
 
  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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 CGM. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation does not show the enrollee requires multiple (three or more) daily doses of insulin. The documentation does not show the enrollee requires treatment with a 
continuous subcutaneous insulin infusion pump. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Libre 2 CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis and a heel stabilizer (L1971, L3170) 
provided on February 16, 2022. 
 
You asked the Plan to pay for the foot orthotics. You say that the items should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the items denied correctly as the record does not 
contain sufficient documentation to support the items billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the information should include the patient's 
diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, 
clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other 
therapeutic interventions and results, past experience with related items, etc.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the foot orthotics have not been met. 
 
There is not sufficient documentation of the enrollees medical condition to substantiate the necessity for the 
ankle foot orthosis and heel stabilizer in dispute. Specifically, there was no information regarding the enrollees 
clinical course, prognosis, or the nature and extent of functional limitations. Therefore, we decided that the 
Plan does not have to pay for ankle foot orthosis and a heel stabilizer (L1971, L3170) provided on February 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty services 
 
You asked the Plan to pre-approve total hip arthroplasty services. You say that the in-network doctor that the 
Plan referred you to will not perform the requested surgery due to risk factors. You say that this doctor referred 
you to the out-of-network provider, who will perform the surgery. The Plan denied your request. The Plan says 
they agree with their network doctor's recommendation, but that if you want to proceed with the out-of-network 
provider you could use your Freedom Plan benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that except for emergency and urgently needed services, plans are 
not required to make payments for any services received by enrollees that are not provided directly by the Plan 
or through arrangements made by the Plan. 
 
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 total hip arthroplasty services. Our reviewer says that total hip arthroplasty services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures directed to the left hip. Moreover, the 
enrollee is noted to have had issues with the bilateral knee replacements, including ulcer formation, cellulitis, 
deep vein thrombosis (DVT), and significant weight gain. 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. 
 
We looked at this physician's review, the file, and Medicare rules. The services at issue in this appeal will not 
be provided in an emergency or urgent care situation. The Plan is not providing these services and is not 
making arrangements to provide these services. Based on this information, we decided that Medicare rules for 
coverage of total hip arthroplasty services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total hip arthroplasty services
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J2777). 
 
You asked the Plan to pre-approve Vabysmo. You say that the provider does not like to use Avastin. You say 
that Avastin is not approved by the Food and Drug Administration (FDA). You also say that this puts the 
enrollee at high risk to get eye infections and can slow the enrollee's treatment. The Plan denied your request. 
The Plan says the enrollee has not tried and failed the preferred drug, Avastin. 
 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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed the preferred drug. The reviewer found that there is no indication that 
the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J2777).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. There remains a dearth of randomized, blinded clinical studies 
examining the long-term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty. 
 
You asked the Plan to pre-approve total disc arthroplasty. You say that the services are necessary. The Plan 
denied your request. The Plan says the requested service is not covered since the enrollee is under 60 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar artificial disc replacement is not 
reasonable and necessary in beneficiaries 60 years of age and younger. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of total disc arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-
approve total disc arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 3 power wheelchair and 
accessories. 
 
You asked the Plan to pre-approve a replacement Group 3 power wheelchair and accessories. You say that you 
returned your previous wheelchair as it was too hard for you to use. You say that you currently do not have a 
chair. You also say that the supplier signed a ticket to say that the wheelchair was returned. The Plan denied 
your request. The Plan says the power wheelchair is less than five years old. The Plan also says that it cannot 
be replaced. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement Group 3 power wheelchair and accessories have not been met. The provided 
documentation does not indicate that the wheelchair sustained loss or irreparable damage. Since the wheelchair 
is less than five-year old it is still within its reasonable useful lifetime so replacement due to wear is not 
covered. Therefore, we decided that the Plan does not have to pre-approve a replacement Group 3 power 
wheelchair and accessories.