Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says 
that  that the radiofrequency ablation of the facet joint nerves 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 the radiofrequency ablation. Our 
reviewer says that the enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee 
has a history of chronic back pain and has previously had surgery at level L5-S1 but has had continued pain. 
The enrollee also has a radiofrequency ablation on April 4, 2022, at level L4-L5 and L5-S1 which provided 
80% pain relief. The request of a repeat radiofrequency ablation meets the criteria of degree and duration of 
pain relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation have been met. Therefore, we decided that the Plan 
has to pre-approve the radiofrequency ablation.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization. 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requested service 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 lower extremity angiography and 
revascularization. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found while the enrollee has a history of peripheral vascular 
disease, the non-invasive studies provided are not consistent with severe disease. The enrollee can walk 5 
blocks before experiencing leg symptoms. In summary, there is insufficient documentation to support the 
medical necessity for lower extremity angiography and revascularization 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 lower extremity angiography and revascularization have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lower extremity angiography and 
revascularization.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve romosozumab (Evenity) (J3111). 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
failed any first line osteoporosis therapies, including both bisphosphonates and Prolia. The Plan also says there 
is no documented intolerance, FDA labeled contraindication, or hypersensitivity to all bisphosphonates and 
denosumab (Prolia). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Evenity. Our reviewer says that Evenity 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found as summarized in the 
Medicare-approved major drug compendia: Romosozumab (Evenity) is approved by the Food and Drug 
Administration as the originator biological product for the treatment of osteoporosis in postmenopausal women 
at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or 
patients who have failed or are intolerant to other available osteoporosis therapy. Romosozumab may be 
considered for patients unable to use oral therapy and as initial therapy for those at very high fracture risk.  
 
Our reviewer found that the provided records in this case do not support that the enrollee is high or very high 
risk for fracture or has failed, is intolerant to other available osteoporosis therapy, or is unable to use oral 
therapy. In addition, Evenity is contraindicated in hypocalcemia, and the enrollee in this case is reported to "not 
intake a lot of calcium." Our physician reviewer found that a normal serum calcium level is not documented in 
this enrollee's available medical records. The use of Evenity is not supported by one of the major drug 
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved 
medical journal without documentation of high risk for fracture as defined above and with no documented 
failure of other available osteoporosis therapy and without documentation of normocalcemia. Our physician 
reviewer also found that the use of Evenity is not indicated, supported, or recommended in any of the 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve romosozumab (Evenity) (J3111).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 24, 2022, to 
June 21, 2022. 
 
You asked the Plan to pay for home health services. You say that you have appealed many times and are not 
past your timely filing. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 24, 2022. A valid NOA was not received by the Plan. As more than 
30 days passed since the timely filing date, no payment can be made on this claim. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from May 24, 2022, to June 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 06, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the acupuncture services. You say that the services should be covered. The 
Plan denied your request. The Plan says services are not covered when obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovascular repair of the infrarenal aorta (34705, 34713). 
 
You asked the Plan to pre-approve endovascular repair of the infrarenal aorta. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary as records 
do not show that the abdominal aortic aneurysm (AAA) is greater than 5.0 centimeters (cm) in diameter nor has 
it increased in diameter by more than 1.0 cm within 12 months or by more than 0.5 cm over 6 months. The 
enrollee is also asymptomatic. 
 
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 endovascular repair of the infrarenal 
aorta. Our reviewer says that the requested items/services are considered medically reasonable and necessary in 
this case. Our physician reviewer found while size criteria are available as general guidelines, they are not the 
only factors in deciding on whether to proceed with AAA repair. Other factors include the morphology of the 
aneurysm, size of the patient/non aneurysmal aorta and other patient factors including patient bias. While the 
aneurysmal growth has not been particularly rapid, it is significant. In this case the patient also has an allergy to 
a type of metal found in most endografts. Should she require AAA more emergently, the specific graft might 
not be available; she would benefit from having this addressed electively while the metal allergy is recognized. 
Additionally, the patients AAA is only a few millimeters from meeting strict coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular repair of the infrarenal aorta have been met. Therefore, we 
decided that the Plan has to pre-approve endovascular repair of the infrarenal aorta (34705, 34713).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the rehabilitation center is your only hope at 
improving. The Plan denied your request. The Plan says medical records do not show a need for daily skilled 
nursing or therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat bariatric surgery (43644). 
 You asked the Plan to pre-approve the repeat bariatric surgery. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   
 
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 repeat bariatric surgery. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that you had a previous bariatric surgery with weight loss but are now regaining weight.  The record provided 
does not document clinical circumstances that demonstrate the reasonability and necessity 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 the repeat bariatric surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the repeat bariatric surgery (43644).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the phlebectomy (37765). 
 
You asked the Plan to pre-approve the phlebectomy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy.   
 
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 phlebectomy. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the patient has not yet undergone 
saphenous vein reflux treatment. 
 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 phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the phlebectomy (37765).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric (J1437). 
 You asked the Plan to pre-approve Monoferric. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 the 
enrollee does not meet the coverage criteria. Our physician reviewer found the Plan requires a trial of Venofer 
(iron sucrose) before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). Our reviewer also found that there is no documentation provided indicating that the Plan's 
required drug(s) 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 (J1437).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 for date of service November 11, 2022. 
 
You asked the Plan to pay for procedure code 99204. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed are 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, the CPT Code Manual definition of 
code 99204 is office or other outpatient visit for the evaluation and management of a new patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. 
 
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 code 99204. Our reviewer says that the 
documentation does support the code billed. Our reviewer found the enrollee presented to an outpatient clinic 
for lower back pain. The documentation supports a comprehensive history, exam, and an appropriate medical 
decision making complexity. Therefore, code 99204 is 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 code 99204 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99204 for date of service November 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 Receiver Device.  
You asked the Plan to pre-approve the Dexcom G7 Receiver Device. The Plan denied your request. The Plan 
says after review of the medical records we did not see any insulin use or any records documenting low blood 
glucose levels. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 Receiver Device. Our 
reviewer says that the Dexcom G7 is not medically necessary. Our physician reviewer found coverage criteria 
require either low blood glucose sugar and insulin use for CGM coverage. The enrollee is on a medication that 
does not cause low blood glucose sugar and we are not told of any low blood glucose sugar. Criteria are not 
met for the CGM coverage and we are not told why a finger stick meter would not suffice. 
 
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 Dexcom G7 Receiver Device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Dexcom G7 Receiver Device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service February 2, 
2022, to March 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that an NOA was submitted in February 2022. The 
Plan denied your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 2, 2022. A valid NOA was not received by the Plan until July 30, 
2022. The file does show that an NOA was submitted in February 2022, however, it was not submitted with the 
correct type of bill code. As more than 30 days passed between the timely filing date and the valid NOA 
receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the 
home health care billed for dates of service February 2, 2022, to March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 for date of service October 18, 2022. 
 
You asked the Plan to pay for procedure code 81479. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 81479 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 for date 
of service October 18, 2022.