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

 
We decided that the Plan has to pre-approve laparoscopic gastric bypass and associated inpatient hospital 
admission (43644,43239). 
 
You asked the Plan to pre-approve laparoscopic gastric bypass and associated inpatient hospital admission. 
You say that the services are necessary. The Plan denied your request. The Plan says that based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy 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 laparoscopic gastric bypass and 
associated inpatient hospital admission. Our reviewer says that the services are medically necessary. Our 
physician reviewer found the enrollee meets LCD criteria for documentation of BMI of at least 35, it is 36 
kg/m2. The enrollee documents diabetes mellitus. The enrollee has participated in weight loss efforts within a 
structured weight management program within the past 12 months without success. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopic gastric bypass and associated inpatient hospital admission have 
been met. Therefore, we decided that the Plan has to pre-approve laparoscopic gastric bypass and associated 
inpatient hospital admission (43644,43239).  
 
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 pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no documentation of lymphedema of an 
extremity. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a periprostatic hydrogel spacer 
(SpaceOAR). 
 
You asked the Plan to pre-approve placement of a periprostatic hydrogel spacer (SpaceOAR). You did not 
provide a specific argument with your appeal request. The Plan denied your request. The Plan says placement 
of a periprostatic hydrogel spacer (SpaceOAR) is not considered reasonable and necessary. The patient does 
not have low or favorable intermediate prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that i order for a prostate rectal spacer to be covered, the 
patient must have low or favorable intermediate prostate cancer. 
 
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 placement of a periprostatic hydrogel 
spacer (SpaceOAR). Our reviewer says that placement of a periprostatic hydrogel spacer (SpaceOAR) is not 
medically necessary in accordance with Medicare rules. Our physician reviewer found the records do not show 
that the enrollee has low or favorable intermediate prostate cancer as required for coverage. The patient is a 81-
year-old male with high-risk prostate cancer and non-muscle invasive high grade bladder cancer. His baseline 
prostate specific antigen (PSA) was 21 with no metastasis on magnetic resonance imaging (MRI). Pathology 
shows Gleason 4+4=8 prostate cancer. He was started on androgen deprivation therapy with Lupron.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a periprostatic hydrogel spacer (SpaceOAR) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve placement of a periprostatic hydrogel spacer 
(SpaceOAR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the AVISE CTD test genetic panel (0312U) provided June 
8, 2022. 
 
You asked the Plan to pay for  the genetic testing . You say that please see the attached documents and below 
information regarding the test that was deemed medically necessary bye enrollee's physician. The Plan denied 
your request. The Plan says the AVISE CTD test panel is considered experimental and investigational.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. This test is unproven to alter disease prognosis or treatment 
outcomes. Screening genetic testing is not a covered service under Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for  the AVISE CTD test genetic panel (0312U) provided June 8, 2022.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 is medically stable. The enrollee's rehab needs can be provided in an 
alternate and low intensity setting such as in-home with services or in a skilled nursing facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 6, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321). 
 You asked the Plan to pre-approve Hyalgan. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been met. 
 
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 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Euflexxa before they will approve the requested drug. You have osteoarthritis of the 
knee. The requested drug is a new start. The provided records do not indicate that you have tried and failed the 
Plan's preferred step-one alternative. The record does not indicate that you have a contraindication to, or would 
have an adverse effect from, the Plan's preferred step-one alternative. 
 
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 treatment with Hyalgan (J7321).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sleep studies (95810, 95811). 
 
You asked the Plan to pre-approve sleep studies. 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 sleep testing 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 sleep studies. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the in-lab sleep study at issue in this case meets all Medicare criteria for 
medically reasonable and necessary for the enrollee. Provided records in this case do not document a face-to-
face clinical examination with a physical examination that documents neck circumference. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sleep studies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sleep studies (95810, 95811).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service December 7, 
2022, to December 13, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service December 7, 2022, to December 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplant listing. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
your dialysis attendance is a contraindication. 
 
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 requested services. Our physician 
reviewer found that you have end-stage renal disease. You have social challenges with children and problems 
with compliance with hemodialysis treatments. Non-compliance with dialysis does not disqualify someone 
from transplantation. Sometimes, given the social situation, transplantation is the best option because of 
challenges. The decision as to whether you are a transplant candidate is up to the transplant center. Different 
centers have different criteria. Given your age, transplant is your best long-term option. There is nothing in the 
history that shows you will not be able to care for a transplant. Hemodialysis involves 12-13 appointments per 
month and is quite the challenge for many. In this case, it is reasonable to refer to transplant center and get 
evaluated for transplant. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve a kidney transplant listing.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the requested Minuteman device is 
medically necessary. The Plan denied your request. The Plan says the requested Minuteman 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 a Minuteman device. Our reviewer says 
that the requested Minuteman device is not medically necessary. Our physician reviewer found the Minuteman 
device is experimental. More research is needed at this time. 
 
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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. 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. 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 intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without foraminal 
stenosis. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a relationship with this 
provider. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 file shows that the enrollee has 
not seen this provider since July of 2022. 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 a referral to an out-of-network 
neurologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, test socket, below knee 
(L5620), an addition to lower extremity, below knee, total contact (L5637), an addition to lower extremity, 
below knee suction socket (L5647) and an addition to lower extremity, socket insert, multi-durometer, below 
knee (L5665). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested items are medically necessary. The 
Plan denied your request. The Plan says the requested parts exceed the enrollee's need and cannot be approved. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per L33787, the requested additions are for below knee prostheses not for a foot prosthesis. The 
enrollee does not meet criteria for the additions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower extremity, test socket, below knee (L5620), an addition to lower 
extremity, below knee, total contact (L5637), an addition to lower extremity, below knee suction socket 
(L5647) and an addition to lower extremity, socket insert, multi-durometer, below knee (L5665).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
May 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 
You asked the Plan to pre-approve Hyalgan injections. You say that due to the enrollee's medical issues 
injection of medication is the best option. The Plan denied your request. The Plan says the enrollee did not 
meet the step therapy requirements. 
 
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 injections. Our physician 
reviewer found that the Plan requires a trial of drugs Synvisc, Synvisc-One, Durolane, and Gelsyn-3 before 
they will approve Hyalgan. Our physician reviewer found that based on the medical records provided there is 
no indication that the enrollee has tried and failed the required drugs. Our physician reviewer found that there is 
no indication that the Plans required drugs 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 Hyalgan injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyalgan injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies billed with 
code K0553 for December 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the units exceed the days in time span. 
 The Plan must follow Medicare rules. The rules say that a supplier does not have to deliver supplies used with a 
CGM every month in order to bill code A4238 or A4239 every month. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with code K0553, not 
A4238 or A4239 as listed in the Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor (CGM) supplies billed with code K0553 for December 31, 2022.