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

 
We decided that the Plan does not have to pre-approve Supartz. 
 You asked the Plan to pre-approve Supartz. You say that the enrollee's doctor believes that the enrollee will 
significantly benefit after injecting bilateral knees to reduce the pain. The Plan denied your request. The Plan 
says based on the information provided, medical necessity is not 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 Supartz. Our reviewer says that the 
enrollee does not meet the coverage criteria for Supartz. Our physician reviewer found the Plan requires a trial 
of drug Synvisc or Orthovisc before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 14, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the requested ILR is medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested ILR. 
 
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 ILR. Our reviewer says that the 
enrollee does not meet criteria for the requested ILR. Our physician reviewer found there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR.  In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic nerve stimulator (E0730) replacement 
batteries (A4630) lead wires, pair (A4557) electrical stimulator supplies (A4595) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a TENS device and supplies. You say that you are appealing the denied 
medical items. You have had lower back pain since August 18, 2022. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 
electronic nerve stimulator (E0730) replacement batteries (A4630) lead wires, pair (A4557) electrical 
stimulator supplies (A4595) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 
 
You asked the Plan to pay for procedure codes 87631 and 99072 for date of service August 9, 2022.. 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 codes 
87631 and 99072 for date of service August 9, 2022. have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87631 and 99072
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) radiologic 
examination; tibia and fibula (73590) immunization administration (90471) Tetanus, Diphtheria and Pertussis 
vaccines (90715) provided December 29, 2022. 
 
You asked the Plan to pay for the emergency services. You say that please have a look this appeal and 
reprocess the claim. The Plan denied your request. The Plan says the services was rendered by a provider who 
does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) radiologic examination; tibia and fibula (73590) immunization administration (90471) Tetanus, Diphtheria and 
Pertussis vaccines (90715) provided December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at levels T9-T12. 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested procedure 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 kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, 
less invasive conservative care measures is not evident. Additionally, the provided diagnostic imaging studies 
corroborated plausible other causes of the noted pain. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception.  
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at levels T9-T12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on December 20, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. 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 the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation procedure.  
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure meets the 
criteria, and the enrollee has tried and failed conservative treatment. The Plan denied your request. The Plan 
says the Intracept procedure 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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Food and Drug Administration (FDA) approval for the Intracept procedure states 
that it is  intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral 
nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent 
with Type 1 or Type 2 Modic changes on advanced imaging.  
 
In this case, there were/are multiple plausible pathologic sources of significant pain generation. The 
predominantly axial back pain, the painful spinal motion (in all directions), and intact neurologic exam 
were/are all non-specific to any pathologic entities. Overall, documentation was/is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L5 and S1 is not medically reasonable and 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept basivertebral nerve ablation procedure.
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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a level 3 (K3) prosthetic foot. 
 
You asked the Plan to pre-approve the requested services. You say that the request will provide greater 
comfort. The Plan denied your request. The Plan says the request is not supported by the medical record.  
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are 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 the enrollee had a right transtibial amputation after multiple failed bypasses. Activities 
include cooking, yard work, home maintenance, gardening, shopping, cleaning. The enrollee uses a walker to 
get from a pickup truck to inside of the house. Variable cadence activity includes long walks and a pool for 
exercise. The documentation does not support that the enrollees activities and function require a K3 level foot. 
The request exceeds the enrollees functional needs and is not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a level 3 (K3) prosthetic foot.
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 services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 the documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH (e.g., multiple and prolonged intravenous therapies, monitoring of significantly 
medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound 
care for multiple wounds stages 3 and above, the need for specialized high-tech equipment like cardiac 
monitors, on-site dialysis, or surgical suites). The enrollee does not require services at the LTACH that are not 
available at the acute care hospital or the skilled nursing facility. The enrollee has improved medically but 
continues to require care in an acute hospital. He can receive further care at the current acute care hospital or a 
lower level of care when deemed appropriate. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that please see 
attached documentation to support this appeal. The Plan denied your request. The Plan says the enrollee does 
not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic 
pneumatic compression device of either E0650 or E0651. 
 
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) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implantation of wireless CardioMEMs 
HF System (33289).  
 
You asked the Plan to pre-approve the services. You say that CardioMEMsis required to monitor the enrollee 
and prevent frequent hospital visits due to fluid overload.  The Plan denied your request. The Plan says there is 
not enough medical proof to show the safety and/or success for heart failure monitoring.  
 
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 services. 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 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 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transcatheter implantation of wireless CardioMEMs HF System (33289).
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at a skilled 
nursing facility. The enrollee has improved medically and can receive further care at a lower level of care when 
deemed appropriate. 
 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.