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

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs.  
 
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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of Prolia or Reclast before they will approve the 
requested drug. In this case, the enrollee has not tried and failed a required drug. There is no documentation 
provided indicating that the Plans required drugs would likely be less effective or likely have adverse effects 
for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy and hyperbaric oxygen 
therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have not failed with standard wound care treatments.  
 
The Plan follows Medicare rules. Medicare rules say that wound care is only covered under certain medical 
indications. 
 
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 there is no evidence that negative pressure wound therapy is currently medically necessary 
and reasonable. There is no evidence that you currently have a medically accepted indication for hyperbaric 
oxygen therapy. Therefore, the requested services 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve negative pressure wound therapy and hyperbaric oxygen therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Strata NGS Genetic analysis (81479). 
 
You asked the Plan to pre-approve an unlisted molecular pathology procedure. You say that you disagree with 
the denial and have attached relevant information for the NCCN guidelines. The Plan denied your request. The 
Plan says there is no evidence that the enrollee has been previously tested with same test using NGS for same 
cancer genetic content. 
 
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 an unlisted molecular pathology 
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the review indicates that the enrollee has been diagnosed 
with Stage II Non-Small Cell Lung Cancer and he has not undergone treatment. The review has determined 
that the enrollee does not meet criteria for the requested testing. The testing 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 an unlisted molecular pathology procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Strata NGS Genetic analysis (81479).
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 January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. 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 January 
23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Suprascapular nerve block (64418). 
 
You asked the Plan to pay for the Suprascapular nerve block. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Suprascapular nerve block. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. 
 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 Suprascapular nerve block have not been met. Therefore, we decided that 
the Plan does not have to pay for the Suprascapular nerve block (64418).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs therapy in order to achieve 
maximum independence and to return home. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spine fusion. 
 
You asked the Plan to pre-approve lumbar spine fusion. 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 lumbar spine fusion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no imaging studies showing spinal instability at any segment. Criteria for 
fusion not met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spine fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spine fusion.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (G0299 x869). 
 
You asked the Plan to pre-approve home health services. You say that you are appealing the denial for verbiage 
changes. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that the enrollee is homebound. Therefore, we decided that the Plan does not have to 
pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, 
each 15 minutes (G0299 x869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total right knee arthroplasty (27447) at the inpatient 
level of care. 
 
You asked the Plan to pre-approve an inpatient knee arthroplasty. You say that the enrollee has moderate 
cardiac risk for surgery, making the inpatient level of care medically necessary. The Plan denied your request. 
The Plan says the enrollee does not require prolonged postoperative monitoring and the procedure can be 
performed as outpatient.  
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,  
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient knee arthroplasty. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met in this case.  
Our physician reviewer found that the enrollee is to undergo a procedure that is not on the inpatient only list 
and is not expected to require two midnights of care. The enrollee should present for, undergo, and be 
monitored following the procedure. Should complications arise, warranting a two-midnight stay, the enrollee 
can be converted to inpatient status at that time under the two-midnight rule. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total right knee arthroplasty (27447) at the inpatient level of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft, bone replacement graft each 
additional site in quadrant, biologic materials to aid in soft and osseous tissue regeneration, autogenous 
connective tissue graft procedure and autogenous connective tissue graft procedure each additional contiguous 
tooth, implant or edentulous tooth position in same graft site. 
 
You asked the Plan to pre-approve the dental services. You say that these are not cosmetic procedures, and 
your provider is recommending these services. The Plan denied your request. The Plan says these services are 
not covered under the Plan's dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft, bone replacement graft each additional site in quadrant, biologic materials to aid in soft 
and osseous tissue regeneration, autogenous connective tissue graft procedure and autogenous connective tissue 
graft procedure each additional contiguous tooth, implant or edentulous tooth position in same graft site.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oroantral fistula closure (D7260) and a bone 
replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve an oroantral fistula closure and a bone replacement graft. You say that you 
are in a lot of pain and really need this procedure to be done as soon as possible. The Plan denied your request. 
The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.    Therefore, we decided that the Plan does not have to pre-approve an 
oroantral fistula closure (D7260) and a bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that continued SNF care is not medically necessary. 
 
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 require daily skilled nursing or therapy services. You do not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 23020, 24301) rendered on 
January 19, 2023. 
 
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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 23020: 
 
Capsular contracture release (eg, Sever type procedure)  
CPT 24301: 
 
Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) 
 
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 operative note does not show 
any tendon transfers being. CPT 24301 is not supported. Additionally, the capsular release is included in CPT 
23472; therefore, CPT 23020 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 23020, 24301) rendered on January 19, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of malignant prostate tissue with ultrasound. 
 
You asked the Plan to pre-approve ablation of malignant prostate tissue with ultrasound. You say that the 
requested services are neither experimental nor investigational. You say that the requested treatment is the most 
medically appropriate for the enrollee. You say that the expert's clinical and evidence-based information, the 
enrollee's medical diagnosis and supporting data all show medical necessity to treat the enrollee's cancer and 
preserve his quality of life.  The Plan denied your request. The Plan says that the services in dispute are 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 ablation of malignant prostate tissue 
with ultrasound. Our reviewer says that ablation of malignant prostate tissue with ultrasound is considered 
medically reasonable and necessary in this case.   Our physician reviewer found high Intensity Focused 
Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. HIFU was approved by 
the food and drug administration (FDA) for prostate gland ablation October 9, 2015.  HIFU of the prostate has 
Medicare coverage as of July 1, 2017. More than 100 clinical studies have demonstrated treatment efficacy that 
is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, 
incontinence, and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ablation of malignant prostate tissue with ultrasound have been met. Therefore, 
we decided that the Plan has to pre-approve ablation of malignant prostate tissue with ultrasound.  
 
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 power seat elevation system (E2300) and a power 
standing system (E2301). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says neither Medicare nor the Plan cover the 
requested item. 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 power seat elevation system (E2300) and a power standing 
system (E2301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quick change self-aligning unit (L5617), fluid swing 
and stance phase control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), 
microprocessor control feature (L5856), and flex-walk system (L5981). 
 
You asked the Plan to pre-approve a quick change self-aligning unit, fluid swing and stance phase control, 
stance flexion feature, fluid stance extension, microprocessor control feature, and flex-walk system. You say 
that the knee and foot that are being requested are medically necessary. The Plan denied your request. The Plan 
says the enrollee's current K2 knee and foot are still under warranty, and Medicare does not cover replacement 
costs for items still under warranty. The Plan also says the request of new prosthetic knee and foot exceeds 
your functional need and does not meet the Medicare criteria of reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a quick change self-aligning unit, fluid 
swing and stance phase control, stance flexion feature, fluid stance extension, microprocessor control feature, 
and flex-walk system. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case.  Our physician reviewer found a quick change self-aligning unit (L5617) 
does not serve a primary medical purpose; therefore, this cannot be considered medically necessary. The 
documentation does not support that the enrollee is a K3 level ambulator given their fall history and use of an 
assistive device. Our reviewer found that furthermore, the physician documentation does not support why the 
enrollee is unable to use a hydraulic knee. Our physician reviewer also found that the enrollee's current knee 
and foot are under warranty.  
 
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 quick change self-aligning unit, fluid swing and stance phase control, stance 
flexion feature, fluid stance extension, microprocessor control feature, and flex-walk system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a quick change self-aligning unit (L5617), 
fluid swing and stance phase control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), 
microprocessor control feature (L5856), and flex-walk system (L5981).