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

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says CardioMEMS device is considered unproven and 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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio 300mg every four weeks for one year.  
 
You asked the Plan to pre-approve Entyvio 300mg every four weeks for one year and for reinduction dosing of 
Entyvio 300mg week two and week six. You say that you are requesting reinduction and dose escalation due to 
a recent/current hospital stay and based on medical necessity. The Plan denied your request. The Plan says the 
request for Entyvio every four weeks for one year exceeds the frequency and time frame allowed per the 
clinical policy.  
 
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 Entyvio 300mg every four weeks for 
one year. Our reviewer says that Entyvio 300mg every four weeks for one year is not medically reasonable and 
necessary. Our physician reviewer found that Entyvio 300mg every four weeks for one year does not meet 
Medicare criteria for coverage. The Medicare-approved major drug compendia do not support every four week 
Entyvio dosing for Crohn's disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio 300mg every four weeks for one year have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Entyvio 300mg every four weeks for one year.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 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 does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that the admitting 
physician reasonably would expect the patients necessary hospital care would 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right lower extremity revascularization, 
endovascular, open or percutaneous, iliac artery; initial vessel and femoral, popliteal arteries, unilateral; with 
transluminal stent placements and atherectomy, includes angioplasty (36247, 75630, 37221, 37225). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 services. Our physician reviewer 
found the enrollee has evidence of lower extremity arterial disease, but no evidence of hemodynamically 
significant iliac, femoral or popliteal arterial stenoses. As such, guidelines for PTA are not met. In summary, 
there is insufficient documentation to support the medical necessity for right lower extremity PTA 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the right lower extremity revascularization, endovascular, open or percutaneous, iliac 
artery; initial vessel and femoral, popliteal arteries, unilateral; with transluminal stent placements and 
atherectomy, includes angioplasty (36247, 75630, 37221, 37225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ceramic (D6740 and D6750) 
on tooth # 2 and # 6 and pontic - porcelain/ceramic (D6245) on tooth # 3, # 4, and # 5. 
 
You asked the Plan to pre-approve retainer crown and pontics. You say that this is medically necessary. The 
Plan denied your request. The Plan says this service is denied because the documentation provided does not 
demonstrate any 
specific physical or neurological need or condition that precludes the use of a removable prosthesis. 
 
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 retainer 
crown and pontics when the services are medically necessary and reasonable.  
 
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 retainer crown and pontics. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found all clinical 
documentation was reviewed. The x-rays that were submitted are unreadable. I cannot distinguish the bone 
levels around the teeth or make any diagnosis due it being a photocopy of the x-rays. I am unable to determine 
whether the bridge is medically reasonable or necessary based off the x-rays as they are undiagnostic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown and pontics have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown - porcelain/ceramic (D6740 and D6750) on tooth # 2 and # 6 
and pontic - porcelain/ceramic (D6245) on tooth # 3, # 4, and # 5.
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says  the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility. 
 
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 you have congestive heart failure and pressure ulcers and is living at home with 
weakness. Your medical problems are stable, and there are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this 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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature to support the safety and efficacy, as defined 
by Medicare rules, of the requested service versus standard therapies. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy (BIS) (93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories (K0861, E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2359, E2377, 
E2613, E2622). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options and accessories. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the documentation indicates you have a mobility deficit that impairs MRADLs in the 
home. You are able to use a walker but noted to be a fall risk. You are unable to effectively use a wheelchair 
due to arm weakness. While you may be able to safely operate a PMD the requested K0861 with multiple 
power options exceeds your medical need. You do not require non-proportional input devices, separate display, 
other electronic devices, or an attendant control. The documentation does not support that it is medically 
necessary to control the requested power options through the joystick (drive interface). Your upper extremity 
strength and functional ability as evidenced by being independent for feeding should be sufficient to control 
any power options through their own switches. The Group 3 power wheelchair with multiple power options is 
not medically necessary. Your needs can be met with a simpler power 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 a group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with multiple power options and accessories (K0861, E0953, E0955, E1007, E1012, E1028, E2300, E2311, 
E2313, E2359, E2377, E2613, E2622).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87641 and 87798 billed for date of 
service August 29, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87641 and 87798. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
are not supported for separate billing. 
 
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 codes 87150, 87641 and 87798 are column II codes to column I codes 
87500, 87801 and 87801; however, 87150, 87641 and 87798 were each 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 procedure codes 87150, 87641 and 87798. Our reviewer says 
that these codes are not supported for separate reporting/billing. Our reviewer found these services are not 
separately identifiable as unusual non-overlapping services. The use of the XU modifier with these codes is not 
supported. 
 
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 codes 87150, 87641 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87150, 87641 and 87798 billed for date of 
service August 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block and destruction (64454, 64624). 
 
You asked the Plan to pre-approve a genicular nerve block and destruction. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 a genicular nerve block and destruction. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found genicular nerve ablation is experimental for knee pain. 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 a genicular nerve block and destruction have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a genicular nerve block and destruction (64454, 64624).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 You asked the Plan to pre-approve Genvisc. You say that the services are medically necessary. The Plan denied 
your request. The Plan says there is no indication that the preferred agents would be less effective or cause 
adverse effects for the enrollee. 
 
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 Genvisc. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Plan requires a trial of Orthovisc, 
Supartz FX, Durolane, Monovisc or Synvisc-One before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plan's required drugs would be less effective 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
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 the enrollee does not meet the criteria for admission 
to an IRF. The Plan denied your request. The Plan says the services are medically necessary. 
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PainTEQ LinQ device for a sacroiliac (SI) fusion. 
 
You asked the Plan to pre-approve the PainTEQ LinQ device. You say that the LinQ procedure meets all the 
Centers for Medicare and Medicaid Services (CMS) requirements for procedures or services that are 
considered reasonable and necessary. The Plan denied your request. The Plan says the PainTEQ LinQ device 
for a sacroiliac fusion is not medically necessary. The Plan says the device is still being studied to see if the 
treatment is investigational and experimental. 
 
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 PainTEQ LinQ 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 was being treated for sacroiliitis. The detailed documentation is not evident regarding imaging or radiographic evidence supporting a sacroiliitis pathology. There is no clear 
history of SI joint pain onset or failure of conservative treatment directed to the SI joint. Other plausible pain 
generators (including at the lumbosacral spine) are evident. 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 or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested PainTEQ LinQ for a sacroiliac fusion 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 the PainTEQ LinQ device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the PainTEQ LinQ device for a sacroiliac (SI) fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee has arthritis in the left 
knee and needs the ablation. The Plan denied your request. The Plan says the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
the radiofrequency ablation is considered experimental and investigational therapy, and is the subject of 
ongoing clinical trials. 
 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.