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

 
We decided that the Plan does not have to pre-approve an L2 and L5 kypohplasty.  
 
You asked the Plan to pre-approve the kyphoplasties. You say that the enrollee has a history of a previous 
compression fracture at L4. You say that the enrollee's bone density study revealed osteopenia. You also say that the retropulsion at L3 is mild and only 3 millimeters and there is no retropulsion at L5. The Plan denied 
your request. The Plan says the documentation does not clearly indicate the enrollee's pain is primarily due to 
vertebral compression fracture. The Plan also says the this is not medically reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that both percutaneous vertebroplasty (PVP) and 
percutaneous vertebral augmentation (PVA) will be considered reasonable and necessary for osteoporotic 
conditions when a vertebral compression fracture is present. 
 
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 kyphoplasties. Our reviewer says 
that the requested kyphoplasties are not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding worsening pain. There is no indication of a progression of the body 
height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is magnetic resonance 
imaging (MRI) corroboration of retropulsion and other plausible causes of back pain. Therefore, the reviewer 
found that the requested kyphoplasties are 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 kyphoplasties have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an L2 and L5 kypohplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 17, 2023, billed with 
codes 87481, 87500, 87511, 87640, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that the physician ordered the medically 
necessary Guidance UTI test as the enrollee has a history of chronic urinary tract symptoms that have failed to resolve with standard treatment. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 17, 2023, billed with codes 87481, 87500, 87511, 87640, 87653, 87798, and 87801.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization procedures (37228, 37229, 37230, 
37231). 
 
You asked the Plan to pre-approve revascularization procedures. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve revascularization procedures. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the procedures 
in question. The enrollee has a history of lumbar spine disease and back surgery. The documentation of symptom details is not suggestive of claudication or ischemic rest pain. The evaluation is not accompanied by a 
physiologic study such as an ankle-brachial index (ABI). An essentially normal computed tomography 
angiography (CTA) other than stenoses in the posterior tibial artery and anterior tibial artery with a patent 
peroneal artery is not consistent with claudication. In general, tibial intervention in the absence of limb threat is 
not advisable as there is a chance of doing more harm than good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization procedures have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization procedures (37228, 37229, 37230, 37231).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Orthovisc, Synvisc, Synvisc-One, or Monovisc 
before it will approve Hyalgan. 
 
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 Hyalgan. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Hyalgan. Our physician reviewer found the 
enrollee has not tried and failed one of the Plan's preferred drugs of Orthovisc, Synvisc, Synvisc-One, or 
Monovisc. The record does not show that one of these drugs would likely be less effective and/or 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Hyalgan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relese (Q4287). 
 
You asked the Plan to pre-approve Relese. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Relese. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Relese is not endorsed by national clinical guidelines and 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 Relese have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Relese (Q4287).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF services provided on September 
30, 2022. 
 You asked the Plan to pay for the SNF services. You say that you have submitted a corrected claim and 
medical records. The Plan denied your request. The Plan says you did not submit the original claim with a valid 
HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that HIPPS codes are alpha-numeric codes of five 
digits.  In this case, you submitted the claim with only a 4-digit code of OKPE.  You need to append the correct 
digit in the 5th place in order for the HIPPS code to be valid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF services provided on September 30, 2022. 
 
Please note that this decision is just based on the Plans denial of your original claim.  Any questions regarding 
the submission of a corrected claim need to be sent to the Plan directly.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that it would be difficult to determine the pancreatic head on 
a daily basis without IGRT. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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 IGRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found while in this case the intent is clearly palliative, there is a basis for IGRT provided. The 
enrollee has ascites which changes day-to-day and can make alignment with surface markers less reliable. Also, 
the target abuts small bowel. IGRT is an accepted standard of care when alignment would be compromised 
without daily pre-treatment imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
image-guided radiation therapy (IGRT).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee can get the services they need at a lower 
level of care.  
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 the 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 an 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 these services are medically necessary. The Plan 
denied your request. The Plan says the required services can be provided in an alternate setting. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 lower extremity revascularization procedures (37224, 
37225, and 37226). 
 
You asked the Plan to pre-approve lower extremity revascularization procedures. 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 lower extremity angiography is 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 lower extremity revascularization 
procedures. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
there is insufficient description of the enrollees symptoms in the evaluation suggestive of claudication or limb 
threat. Palpable pedal pulses are documented as are normal ankle-brachial indexes (ABIs). An isolated finding 
of elevated velocities in the common femoral artery on duplex does not, in itself, constitute a need for 
intervention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity revascularization procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lower extremity revascularization procedures (37224, 
37225, and 37226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion. 
 
You asked the Plan to pre-approve Vertiflex Superion. You say that this treatment is considered safe and 
effective. The Plan denied your request. The Plan says interspinous decompression systems (without fusion) for 
the treatment of spine pain or spinal stenosis are unproven and not medically necessary due to insufficient 
evidence of efficacy. 
 
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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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 Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim device. You say that Barostim is Food and Drug Administration 
(FDA) approved and currently covered by Medicare. The Plan denied your request. The Plan says a review of 
the current medical literature does not consider this service to be standard medical treatment for 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 a Barostim device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary 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 a Barostim device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Barostim device (0266T, C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (40 fractions). 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton beam therapy minimizes the 
chances of the enrollee having post-treatment complications. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for proton beam therapy. 
 
The Plan follows Medicare rules. Medicare rules state that proton beam therapy may be covered if certain 
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 proton beam therapy. Our reviewer says 
that the enrollee does not meet criteria for proton beam therapy. Our physician reviewer found proton therapy 
for prostate cancer is not experimental; however, any potential benefit or detriment of proton therapy over 
standard intensity-modulated radiation therapy (IMRT) is an investigational question. Other treatment 
approaches are also highly effective and well tolerated. Dose constraints to normal tissues do not limit the total 
dose of radiation safely deliverable to the tumor with other indicated methods. There is not a reason to believe 
that doses generally thought to be above the level otherwise attainable with other methods might improve 
control rates. Higher levels of precision associated with proton beam therapy as compared to other methods are 
not 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (40 fractions).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve InnovaMatrix AC, per sq cm (A2001). 
 
You asked the Plan to pre-approve InnovaMatrix AC. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve InnovaMatrix AC. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that documentation does not demonstrate adequate blood 
flow to the leg wounds. The podiatrist noted concern for vasculitis and for adequate blood flow in both of the 
enrollee's legs, with reduced pulses, and he was referred to a vascular specialist however the results of this evaluation was not submitted. The review has determined that the items/services at issue in this case are 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 InnovaMatrix AC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve InnovaMatrix AC, per sq cm (A2001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested Minuteman procedure 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 a Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure (22840, 22612).