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

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has 
age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare guidelines for care in an LTACH. 
 
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 appears to be improving but is currently still unstable and requires short-
term additional acute care hospital services that can safely be administered at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and 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: 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 are significantly declining every day and not 
receiving therapy in the hospital, you need intense rehab, aggressive therapy because you cannot do anything 
on your own and a skilled nursing facility is not enough assistance. The Plan denied your request. The Plan 
says your records do not show you need an intensive team for your care, services you need can be provided 
safely in other settings, a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on July 8, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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 the medical 
records do not support the billing of code 99223. Our reviewer found the review has determined that the 
medical records supported a comprehensive history and medical decision making of high complexity but not a 
comprehensive examination. 
 
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 provided on July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 provided on August 26, 2021, and 
August 27, 2021. 
 
You asked the Plan to pay for procedure code 99233. You say that the medical records support the billing of 
code 99233. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99233. 
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 99233. Our reviewer says that the medical 
records do not support the billing of code 99233. Our reviewer found the review has determined that the 
medical records supported a detailed examination but not a detailed interval history and medical decision 
making of high complexity. 
 
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 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99233 provided on August 26, 2021, and August 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the provider believes the enrollee requires IRF 
services. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval. 
 
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 enrollee has modest functional loss and cognitive impairment. The enrollee 
has a level of functional loss routinely managed in settings other than an IRF. The enrollee does not require 
intensive therapy or frequent physiatry oversight. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 enrollee has standard post-acute rehabilitation needs that are reasonably 
addressed without an IRF admission. The enrollee does not require intensive rehabilitation services per 
evidence based and clinical practice standards. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental in cases of spinal surgery when used as bone 
graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 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 a CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator 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 the home ventilator. Our physician 
reviewer found 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 be provided by a bilevel 
positive airway pressure (BiPAP) device with AVAPS and a back-up rate. The provided records do not 
document trial and failure of 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Paclitaxel (J9267), Carboplatin 
(J9045), Dexamethasone (J1100), and Diphenhydramine (J1200). 
 
You asked the Plan to pre-approve Keytruda, Paclitaxel, Carboplatin, Dexamethasone, and Diphenhydramine. 
You say that you would like the enrollee to start this medication due to their cancer diagnosis. The Plan denied 
your request. The Plan says the use of this regimen is not reasonable and 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 Keytruda, Paclitaxel, Carboplatin, 
Dexamethasone, and Diphenhydramine. Our reviewer says that the requested drug regimen is not medically 
reasonable and necessary for the enrollee. Our physician reviewer found monotherapy with Keytruda carries an 
off-label indication for advanced anal cancer and the combination of Paclitaxel and Carboplatin are indicated 
for anal cancer, but the combination of Keytruda, Paclitaxel, Carboplatin, Dexamethasone, and 
Diphenhydramine is not FDA-approved for the treatment of squamous cell carcinoma of the anal canal. The 
requested combination of drugs is not supported by one of the major drug compendia or by clinical research 
that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal for the treatment 
of squamous cell carcinoma of the anal canal. Our physician reviewer also found that the combination of 
Keytruda, Paclitaxel, Carboplatin, Dexamethasone, and Diphenhydramine is not indicated, supported or 
recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Paclitaxel, Carboplatin, Dexamethasone, and Diphenhydramine have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271), Paclitaxel 
(J9267), Carboplatin (J9045), Dexamethasone (J1100), and Diphenhydramine (J1200).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99490 and 99439 provided on May 27, 
2022. 
 
You asked the Plan to pay for procedure codes 99490 and 99439. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 99490 and 99439 have been met. In this case, the appellant has not provided supporting documentation of the billing provider 
having an initiating face-to-face visit separate of the chronic care management (CCM) service. This face-to-
face visit is not part of the CCM service and can be separately billed to the physician fee schedule (PFS) but is 
required before CCM services can be provided directly or under other arrangements. The billing practitioner 
must discuss CCM with the patient at this visit. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99490 and 99439 provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the pontic-porcelain fused to noble metal (D6242) for teeth 
7,10,12, and 13. We decided that the Plan does not have to pre-approve the retainer crown porcelain fused to 
noble metal (D6752) for teeth 6,8,9,11, and 14.  
 
You asked the Plan to pre-approve the retainer crown porcelain fused to noble metal (D6752) for teeth 6,8,9,11, 
and 14, and the pontic-porcelain fused to noble metal (D6242) for teeth 7,10,12, and 13. You say that 
you would like to place a bridge connecting the enrollee's six implants with codes D6752 and D6242. The Plan 
says that the enrollee's dentist has used an inappropriate code for the procedure being done. The Plan says that 
the benefit limit has been met for D6242. 
 
We decided that the Plan has to pre-approve the pontic-porcelain fused to noble metal (D6242) for teeth 
7,10,12, and 13.  
 
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. Specifically, there is no evidence showing your benefit for the pontic-porcelain 
fused to noble metal (D6242) was previously exhausted. Therefore, we decided that the Plan has to pre-approve 
the pontic-porcelain fused to noble metal (D6242) for teeth 7,10,12, and 13.  
 
We also decided that the Plan does not have to pre-approve the retainer crown porcelain fused to noble 
metal (D6752) for teeth 6,8,9,11, and 14.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the retainer 
crown porcelain fused to noble metal (D6752) for teeth 6,8,9,11, and 14, when the services are medically 
necessary and reasonable. 
 
Our reviewer says that implant body-supported abutment retainers are necessary and usually reported with 
D6068, but the specific service requested in this case (D6068 - ceramic retainer for a fixed partial denture that 
gains retention, support and stability from an abutment on an implant) is not appropriate for the enrollees 
situation. Therefore, we decided that the Plan does not have to pre-approve the retainer crown porcelain fused 
to noble metal (D6752) for teeth 6,8,9,11, and 14. 
 
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.