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

 
We decided that the Plan does not have to pre-approve left total knee arthroplasty. 
 
You asked the Plan to pre-approve left total knee arthroplasty. You say that the patient has failed conservative 
management. The patient attempted physical therapy but could not tolerate it. The Plan denied your request. 
The Plan says left total knee arthroplasty is not medically necessary for this patient. While the records show 
that the patient has moderate to severe arthritis in the left knee, the patient has not participated in a course of 
physical therapy for the left knee. 
 
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 left total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the patient has not tried and failed a recent trial of physical therapy for knee pain. More conservative measures are needed before this knee surgery would be considered 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 left total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left total knee arthroplasty.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 You asked the Plan to pre-approve Monoferric. You say that Monoferric is medically necessary for the patient. 
The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Venofer. 
 
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 Monoferric. Our reviewer says that 
Monoferric is not medically necessary in accordance with the Plan's step therapy rules. Our physician reviewer 
found the enrollee is an 82 year old male with a history of iron deficiency anemia. The provider has requested 
Monoferric to treat the enrollee's condition. The drug is being prescribed for a medically-accepted indication. 
Part B coverage of the requested drug is subject to the Plan's step therapy criteria. The Plan requires a trial of 
drug Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug 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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this is a medically warranted 
treatment. The Plan denied your request. The Plan says there is not sufficient evidence supporting this 
procedure at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a lack 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 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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 home health occupational therapy (OT) 
visits. 
 You asked the Plan to pre-approve the home health OT services. You say that you believe that ongoing therapy 
is needed. The Plan denied your request. The Plan says the enrollee is on a home exercise program, and the 
records do not support the need for additional home occupational therapy visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health OT services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee has major brain damage following a stroke. He is non-ambulatory and has poor sitting balance. He is 
at home after 5 months in a skilled facility and continues with a tracheostomy and feeding tube. He is 
dependent in mobility and daily living activities. He has very limited cognitive capacity. He was discharged 
from OT on April 8 with a home exercise program.  
 
The enrollee has a chronic and severe impairment for which a home exercise program is appropriate. Continued 
services from a skilled therapist are 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 home health OT services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 10 home health occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 4, 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 the documents do not support this level of care. 
 
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, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the key elements of this code are 
absent in the records. The history was abbreviated, and only focused on the hip fracture. The history of heart 
failure and dementia are not explored. There was no mental status exam. There was no review of prior response 
to hospitalization or surgery related to the dementia. A review of systems was not conducted as the template 
states no memory complaints, and this was not addressed. The plan was routine for hip fracture and did not 
utilize a high complexity of decision making. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS heart failure system. 
 
You asked the Plan to pre-approve the CardioMEMS heart failure system. You say that the enrollee meets all 
the indications for the CardioMEMS Heart Failure (HF) System. The Plan denied your request. The Plan says 
the requested device 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 CardioMEMS heart failure system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS heart failure system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the CardioMEMS heart failure system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan of the heart. 
 
You asked the Plan to pre-approve a PET scan.. You say that you are requesting reconsideration for the denial 
of a PET scan of the heart stating it is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet the medical necessity and established criteria for the requested PET scan of the heart. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that other modalities of stress testing have not 
been performed. The guidelines do not support the use of cardiac PET imaging in this role. As a result, cardiac 
PET scanning would not be considered medically reasonable and necessary in this patient'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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scan of the heart.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis eye drops. 
 
You asked the Plan to pre-approve the medication. You say that this is a medically necessary treatment. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Restasis eye drops.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on July 23, 2021 to July 
29, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
member presented to the hospital after a fall. The member was found to have rhabdomyolysis. The member's 
troponin elevated to 1.6 and was secondary to rhabdomyolysis. An elevation of troponin can result from 
myocardial injury other than myocardial infarction or from non-cardiac conditions such as renal failure. 
Therefore, diagnosis code I21.4-Non-st elevation (NSTEMI) myocardial infarction is the appropriate secondary 
diagnosis. The Plan denied your request. The Plan says the records submitted do not support secondary 
diagnosis code I21.4-Non-st elevation (nstemi) myocardial infarction. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis of I21.4 Non-st elevation 
(NSTEMI) myocardial infarction. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the billed secondary diagnosis of I21.4 
Non-st elevation (NSTEMI) myocardial infarction is not supported in the medical record Our physician 
reviewer found the member presented after a fall with evidence of rhabdomyolysis and a urinary tract 
infection.  The members troponin was also elevated. The emergency department provider noted concern for a 
NSTEMI, while the hospitalist attributed the elevated troponin to the rhabdomyolysis. The cardiologist 
ultimately noted that the mild troponin elevation was likely due to supply-demand mismatch.  As such, the 
NSTEMI should be coded as type 2 (I21.A1) not type I (121.4-I21.9).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 23, 2021 to July 29, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says LTACH care is not medically 
necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee at this time. The Plan says 
that the enrollee can remain in the current acute care location until such time that no further acute level of care 
is needed. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genomic testing cooperative liquid trace hematology testing (81455) 
provided on December 8, 2022. 
 
You asked the Plan to pay for code 81455. You say that this testing was medically necessary and reasonable. 
The Plan denied your request. The Plan says that this testing was 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 pay for code 81455. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this patient has refractory follicular lymphoma treated with multiple prior therapies. Next 
generation sequencing (NGS) testing was performed to help guide treatment decision making. NGS testing is 
supported by the National Comprehensive Cancer Network (NCCN) Guidelines and considered a standard 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 code 81455 have been met. Therefore, we decided that the Plan has to pay for 
genomic testing cooperative liquid trace hematology testing (81455) provided on December 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac (SI) joint injections provided on December 14, 
2022. 
 
You asked the Plan to pay for the SI joint injection. You say that this service should be covered. The Plan 
denied your request. The Plan says this SI injection was 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 pay for the SI joint injection. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have not had three months of conservative therapy and there is no documentation of three 
positive SI joint maneuvers to support the SI injection at issue. 
 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 SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the sacroiliac (SI) joint injections provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient has chronic respiratory failure 
and showed improvement on a ventilator while in the hospital. The patient will continue to need a ventilator at 
home, and all alternative therapies have been considered and ruled out. The Plan denied your request. The Plan 
says a home ventilator is not medically necessary because the patient's needs can be met with a bilevel positive 
airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS). 
 
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 a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
The provided records document that the home ventilator is being requested for use in a pressure support (PS) 
mode with a safety tidal volume which could be provided by a BiPAP device with average volume assured 
pressure support (AVAPS) and a back-up rate. The provided records do not document trial and failure of a 
BiPAP device with AVAPS and a back-up rate. 
 
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.