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

 
We decided that the Plan has to pay for extracorporeal photopheresis (ECP) provided to the enrollee on June 
30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there was no documentation that this was provided for bronchiolitis obliterans syndrome 
(BOS) under a clinical research study or any of the other indications. 
 
The Plan must follow Medicare rules. Medicare rules say that service are covered if they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had a single lung transplant for chronic obstructive pulmonary disease (COPD) in 2018. 
The lung function has been declining due to bronchiolitis obliterans syndrome related to rejection, despite 
immunosuppressive therapy. According to the records, ECP was performed as part of a clinical trial. According 
to Medicare rules, "Extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) 
following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical 
research study." 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
extracorporeal photopheresis (ECP) provided to the enrollee on June 30, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spinal canal 
and contents, lumbar. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no discussion of the lumbar spine or low back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that during the last 
encounter on 12/13/22, there is mention of non-specific back pain. However, the neurological exam of the 
lower extremities was negative. There are no lumbar spine x-rays in the chart. The written orders specify MRI 
of the cervical spine, but there is no mention of an order for MRI of the lumbar spine. Absent a documentation 
of the medical necessity of MRI of the lumbar spine the exam should be denied. 
 
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 MRI have not been met.  
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the 
spinal canal and contents, lumbar.
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 device. You say that this 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. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of implantation of the wireless pulmonary 
artery pressure monitoring system (CardioMEMS) for management of congestive heart failure in this patient. 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT) for 
superficial radiation therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful when treating with electron beam, 
superficial radiotherapy, or skin surface brachytherapy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that daily ultrasound imaging is neither necessary nor useful when treating with electron beam, 
superficial radiotherapy, or skin surface brachytherapy. Studies have not shown that this is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound-guided radiation therapy (US-IGRT) for superficial radiation therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, oxygen, and supplies provided on August 16, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport, oxygen, and 
supplies. You say that the ambulance transport was medically necessary as the patient required oxygen during 
transport. The Plan denied your request. The Plan says the service does not meet the medical criteria for 
ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-
emergency transport, oxygen, and supplies. Our reviewer says that the transportation via ambulance from the emergency department to the enrollee's 
residence was not medically necessary. Our physician reviewer found the enrollee did not require the expertise 
of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Oxygen can be administered by a portable tank/concentrator and a layperson. Transportation could have been 
provided by other means (stretcher van, wheelchair van, private care, taxi) without endangering the enrollee's 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport, oxygen, and 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, oxygen, and supplies provided on August 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (Ferric Carboxymaltose). 
 
You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a history of iron deficiency anemia. The documentation does not support that the 
enrollee has tried and failed at least two of the preferred intravenous iron therapies. The documentation does 
not support that at least two of the preferred intravenous iron therapies would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (Ferric Carboxymaltose).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee did not tolerate BiPAP in the hospital because of mask intolerance, so it seems unlikely the 
enrollee will use any home ventilatory support. If able to use it, BiPAP with average volume assured pressure 
support (AVAPS) will likely meet the enrollee's needs. There is no documentation this has been tried as an 
outpatient. Medicare does not cover a home ventilator when used as BiPAP.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections (64635). 
 
You asked the Plan to pre-approve the facet joint injections. You say that this injection is medically necessary. 
The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when 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 the facet joint injections. Our reviewer 
says that the injections are medically necessary. Our physician reviewer found while other pathology is present, 
the enrollee's symptoms correlate well to the MRI and physical exam findings. Previous injections provided 
100% pain relief. 
 
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 facet joint injections have been met. Therefore, we decided that the Plan has 
to pre-approve facet joint injections (64635).  
 
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: Favorable

 
We decided that the Plan has to pay for codes 95938 and 95939 provided on April 20, 2022. 
 
You asked the Plan to pay for codes 95938 and 95939. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that these codes were billed with an invalid diagnosis code. 
 
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. Review of the file shows that these services were billed with diagnosis codes 
S72.90xA (unspecified fracture of unspecified femur, initial encounter for closed fracture), J44.9 (chronic 
obstructive pulmonary disease, unspecified.), and I10 (essential (primary) hypertension). The Plan states that 
these are invalid diagnosis codes and do not support the billed procedure. The documentation did not include 
explanation, citations, or Medicare rules to support this denial. Therefore, the Plan did not substantiate their 
denial.  Therefore, we decided that the Plan has to pay for codes 95938 and 95939 provided on April 20, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a Medicare-covered indication for this service. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope 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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve porcelain/ceramic crowns (D2740 x3). 
 
You asked the Plan to pre-approve porcelain/ceramic crowns. You say that the provider feels as if it is more 
biocompatible than having metal with ceramic on top as a crown near the gum. The Plan denied your request. 
The Plan says that traditional crowns are more durable. Porcelain crowns can better match tooth color but tend 
to be not as durable. As such, cosmetic enhancement does not reach medical necessity threshold. 
 
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 porcelain/ceramic crowns. Our 
reviewer says that the documentation meets the criteria for coverage for porcelain/ceramic crown (D2740) for 
teeth #'s 17, 18 and 19. Our physician reviewer found that although metal crowns are more durable, ceramic 
crowns can be expected to last for 15 years or more. However, more factors are considered in what material to 
use such as biocompatibility (allergies to metals, composition of opposing teeth), amount of tooth structure 
removed and esthetic requirements. In this case the provider determined that ceramic crowns were the 
treatment of choice with respect to biocompatibility. It is medically reasonable that the provider determines the 
choice of 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 porcelain/ceramic crowns have been met. Therefore, we decided that the Plan 
has to pre-approve porcelain/ceramic crowns (D2740 x3).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the preferred products were not tried. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Fulphila and Ziextenzo before they will approve the requested drug. In his case, the patient has not tried 
and failed the required drugs. There is no documentation provided indicating that the plans required drugs 
would likely be less effective and/or likely have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show clear enrollment in a clinical trial. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found routine use of proton therapy for pelvic/prostate radiation is not within accepted standards of medical 
practice. No comparison plan is provided for this patient showing an unacceptable non-proton-based plan. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Roflumilast. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
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 Roflumilast.