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

 
We decided that the Plan does not have to pre-approve inpatient admission and the Conformis customized knee 
implant. 
 
You asked the Plan to pre-approve inpatient admission and the Conformis customized knee implant. 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 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 inpatient admission and the Conformis 
customized knee implant. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested inpatient admission and the Conformis customized knee implant, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission and the Conformis customized knee implant have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission and the Conformis 
customized knee implant.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs device. 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that this device is medically necessary for 
the condition. The Plan denied your request. The Plan says the criteria for coverage of this device 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 the CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has been diagnosed with congestive heart failure (CHF). At issue is the 
medical appropriateness and necessity of implantation of the wireless pulmonary artery pressure monitoring 
system (CardioMEMS) for management of CHF in this patient. The CardioMEMS device was approved by the 
Food and Drug Administration (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 patients with CHF. The clinical study 
on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient 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 patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary in this patients 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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS) (0398T). 
 
You asked the Plan to pre-approve MRgFUS. You say that the enrollee has tried levodopa and carbidopa 
without meaningful relief. You also say that the tremors interfere with the enrollee's activities of daily living. 
The Plan denied your request. The Plan says the requested service is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that MRgFUS is medically necessary for patients with 
medication refractory, moderate to severe postural or intention tremor of the dominant hand, disabling tremor, 
and not a surgical candidate for DBS. 
 
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 MRgFUS. Our reviewer says that the 
requested MRgFUS is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee has any contraindications to deep-brain stimulation (DBS). The reviewer 
found that there was no indication that the enrollee was not a surgical candidate for DBS either. Therefore, the 
reviewer found that the requested MRgFUS is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRgFUS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance image guided high intensity focused ultrasound (MRgFUS) (0398T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 home health occupational therapy visits. 
 
You asked the Plan to pre-approve 8 home health occupational therapy visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 8 home health occupational therapy 
visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have 
had 17 visits. The record does not show response to therapy and does not provide a rationale based on your 
response for continued therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 home health occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 8 home health occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for a 
crutch substitute. Based on this information, we decided that Medicare rules for coverage of a crutch substitute 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute 
(E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E0978, K0806). 
 
You asked the Plan to pre-approve power scooter. You say that the power scooter is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the requested power scooter is not medically necessary. Our physician reviewer found there is no 
documentation that this patient has a personal mobility deficit that impairs participation in mobility related 
activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the 
home. Based on the medical records provided there is no documentation that the patient's mobility deficit 
cannot be helped by the use of a walker or manual wheelchair.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (E0978, K0806).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure is necessary for the 
enrollee. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered experimental. The reviewer also found there is 
no extenuating circumstance noted to support the medical necessity of this request as an exception. Therefore, 
the reviewer found that the requested Intracept procedure is not 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on external, middle, and inner ear 
including biopsy (00120) provided April 1, 2022. 
 
You asked the Plan to pay for the anesthesia. You say that records attached supporting that this procedure was 
performed by your provider. The claim denied as duplicate in error. The Plan denied your request. The Plan 
says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 30, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on external, middle, and inner ear 
including biopsy (00120) provided April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve venous thrombosis imaging, venogram (78457). 
 
You asked the Plan to pre-approve venous thrombosis imaging. You say that this test is medically necessary. 
The Plan denied your request. The Plan says this test is not medically necessary, as it is not supported for any 
indication at this time. Another testing service would provide the necessary results and be more appropriate in 
this case. 
 
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 venous thrombosis imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a radionuclide venogram has been ordered, but no results of a venous 
ultrasound or knee magnetic resonance imaging (MRI) are included in the records. No notes from the 
mentioned "vein specialist" are in the submitted materials. There is no demonstration of the medical necessity 
of the requested venous radionuclide exam which has been requested in the submitted records. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of venous thrombosis imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve venous thrombosis imaging, venogram (78457).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that the device is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet medical necessity for this 
device. Medicare states that for an ILR to be covered, the enrollee must be having syncopal events that are 
thought to be cardiac-related but not able to be detected by either a HolterTM monitor or traditional pre-
symptoms memory-loop recorder. 
 
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 an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while the enrollee has a history of atrial fibrillation, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR 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 an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor (33285).
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 IRF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
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 had sepsis and acute kidney injury. They have had previous skilled 
nursing facility stays. The enrollee does not use an assistive device and has recurrent falls. In this case, the enrollee is functioning at a home care level of rehabilitation. They do not require intensive rehabilitation or 
frequent physiatry oversight at this time as required for IRF 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services by 
physician or other qualified health care professional (96132 x 2). 
 
You asked the Plan to pre-approve NeuroTrax memory test. You say that the enrollee needs this test. You say 
that the enrollee's memory is worsening with difficulty holding conversations. You also say that this test will 
help to rule out dementia. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that psychological testing is limited to physicians, clinical 
psychologists, and on a limited basis, to qualified non-physician practitioners. 
 
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 NeuroTrax memory test. Our reviewer 
says that the requested NeuroTrax memory test is not medically necessary. Our physician reviewer found the 
requested test is not administered by a physician or qualified healthcare professional. Therefore, the requested 
testing is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NeuroTrax memory test have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing evaluation services by physician or other qualified 
health care professional (96132 x 2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada. 
 
You asked the Plan to pre-approve Erleada. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Erleada.  
 Benefits for Erleada 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 the folding wheeled walker, adjustable or fixed height 
(E0143) seat attachment, walker (E0156) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the walker and attachment. You say that the enrollee had back surgery and 
needs the walker to help waling. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the folding wheeled walker, adjustable or fixed height (E0143) seat attachment, walker (E0156) to be provided 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Motegrity. 
 
You asked the Plan to pre-approve Motegrity. You say that this medication is medically necessary for your 
condition. You also say that you have tried and failed other medications. The Plan denied your request. The 
Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 
Medicare Part B. 
 
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 Motegrity.  
 Benefits for Motegrity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.