Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 You asked the Plan to pre-approve Synvisc-One. You say that you were told to try Synvisc-One before the last 
option of surgery. The Plan denied your request. The Plan says Synvisc One (J7325) is not medically necessary 
and not covered. 
 
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 Synvisc-One. Our reviewer says that 
you do not meet the coverage criteria for Synvisc-One. Our physician reviewer found the Plan requires a trial 
of Euflexxa before they will approve the requested drug. In this case, you have not tried and failed the required 
drug. Our reviewer also found that there is no documentation provided indicating that the Plan's required drug 
would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of the enrollee's condition. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system (K0108), bumper (K0108 x2), rigid 
footplate riser (K0108), cup holder (K0108), and footplate width extension brackets (K0108 x2).  

You asked the Plan to pre-approve a transit system, bumper, rigid footplate riser, cup holder, and footplate 
width extension brackets. You say that the items are necessary. The Plan denied your request. The Plan says the 
items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit system (K0108), bumper (K0108 x2), rigid 
footplate riser (K0108), cup holder (K0108), and footplate width extension brackets (K0108 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement surgery. 
 
You asked the Plan to pre-approve the requested services. You say that x-rays show severe osteoarthritis. The 
Plan denied your request. The Plan says the request 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 requested services. Our physician 
reviewer found that the enrollee is being treated for osteoarthritis. She presented with a long history of 
progressive right knee pain starting with a fall approximately 30 years ago. She has had 3 arthroscopic 
debridements. She is now having increasing difficulty with activities of daily living and pain at rest. Her pain is 
rated a 9 out of 10. The exam of the right knee reveals 10 degrees genu varum flexion deformity. There is 
tricompartment pain. Tenderness to palpation over the medial greater than lateral joint line. Patellofemoral 
crepitus is noted. Arc of motion is greater than 90 degrees. There is a 5-degree flexion contracture. However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. The documentation does not support any formal physical 
therapy having been trialed. Additionally, when the enrollee trialed cortisone injections are not clearly 
documented. There is no indication of any trial of viscosupplementation injections or Hyalgan injections. 
Moreover, the enrollees body mass index is 42.9 kg/m2 and the documentation does not evidence any trials of 
weight loss. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested total knee replacement surgery 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detoxification services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have severe symptoms.  
 
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 requested services. Our physician 
reviewer found that this enrollee does not appear to require inpatient treatment as he is not a danger to himself 
or others. He is noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. This enrollee is not showing any symptoms of withdrawal. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient detoxification services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9 months use of a ventilator. You say that you request reconsideration due 
to medical necessity. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of a ventilator. 
 
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 9 months use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that the enrollee was treated with a device in a mode that can be delivered with a bilevel positive 
airway pressure (BiPAP)-average volume-assured pressure support (AVAPS) machine. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of 
such a device has not been documented. The plan has indicated coverage for such a device is available upon 
request. 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 9 months use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) months use of a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified (87798) provided October 28, 2022. 
 
You asked the Plan to pay for  the laboratory service. You say that it is medically necessary for the screening 
and testing of sexually transmitted diseases in individuals to help minimize risks, complications carriers have and to help stop the spread to others. The Plan denied your request. The Plan says this service is considered to 
be experimental or investigational by the Plan and is excluded from coverage. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Nasal swab testing (viral and bacterial), Infectious agent detection by nucleic acid 
(DNA or RNA) was performed. However, polymerase chain reaction (PCR) testing for respiratory illness does 
not currently have current high-quality literature to support its use over standard culture or rapid testing for 
point of care use. There were no provided clinical notes from this visit to provide clinical background to further 
support this request. Therefore, this request will be considered not medically necessary based on the provided 
documentation.  
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for  the infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified 
(87798) provided October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E0956, E1007, E1012, E1028, 
E2300, E2311, E2313, E2377, E2361, E2607, K0040, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that with your medical condition of polio, the requested wheelchair is medically necessary. The Plan 
denied your request. The Plan says you do not have a medical need for multiple power options included with 
K0861 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter 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 standard power wheelchair 
and additional items and accessories. Our reviewer says that you do not meet the coverage criteria for the 
requested Group 3 standard power wheelchair. Our physician reviewer found the enrollee has post-polio 
syndrome, and very weak legs. The enrollee's current wheelchair does not recline. Our reviewer found that the 
enrollee has intact skin. Our physician reviewer also found that the enrollee does not have high risk for skin 
breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing power 
drive. 
 
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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E0955, E0956, 
E1007, E1012, E1028, E2300, E2311, E2313, E2377, E2361, E2607, K0040, and K0108).
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 a history of hip replacement in 2022, and is living at home with 
weakness and trouble ambulating. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does 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. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: 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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
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 was admitted for a fall, anemia, and hemoperitoneum. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 16, 2023, billed with 
code 75743. 
 
You asked the Plan to pay for the services as billed. You say that this was billed correctly and should be paid.  
The Plan denied your request. The Plan says the use of modifier -59 to bypass the edit is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 75743 is a column II code to column I code 37211; however, 75743 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services as billed. Our reviewer says that the 
documentation does not support the modifier -59 as being clinically appropriate. Our reviewer found Current 
Procedural Terminology (CPT) 75743 radiological supervision and interpretation of a selective bilateral 
pulmonary angiography in addition to arterial infusion transcatheter therapy, for thrombolysis other than 
coronary or intracranial, using any method, including radiological supervision and interpretation for service 
provided.  
 
The procedure report documents a pulmonary embolism (PE) thrombolysis with radiological supervision and 
interpretation. The intervention performed includes radiological services, and the documentation does not 
support a separate distinct service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on March 16, 2023, billed with code 75743.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) month use of a ventilator (E0466). 
 
You asked the Plan to pre-approve 9-month use of a ventilator. You say that you are requesting reconsideration 
due to medical necessity. The Plan denied your request. The Plan says the request for continued use of a 
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 9-month use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD with treatment with ventilatory established already, but there is no documented chronic hypoxemia or 
hypercapnia or supporting documentation to indicate why the enrollee was started on a trilogy ventilator. There 
is no documented failure or attempt of bilevel positive airway pressure (BIPAP) in the medical chart, therefore, 
more data is required. Whether or not chronic respiratory failure is present is not able to be established by 
documentation and a decision regarding need is not able to be made with data present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9-month use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) month use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit (K0108). 
 
You asked the Plan to pre-approve a tie down kit. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tie down kit (K0108).