Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and privacy flap for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue are a privacy flap and power seat elevation system. These items are not covered by Medicare 
because they do not serve a purpose that is primarily medical in nature.  
 
The rules say that when one power seating function/actuator/motor is provided on a power wheelchair, one unit 
of E2310 (electronic connection between wheelchair controller and one power seating system motor) is 
allowed. An expandable controller (E2377) and harness (E2313) are not allowed in this situation unless a 
specialty interface is used. 
 
The file shows that the approve PWC has one power seating function. The requested expandable controller 
with harness is not appropriate or covered in this situation. 
 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, expandable 
controller with harness, and privacy flap for a power wheelchair (PWC).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient clinical information to approve the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there is not enough 
clinical information in the documentation to support the CT scan. There is no recent trial and failure of physical 
therapy for low back pain. More conservative measures are needed. There are no red flags for a CT scan. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental canal preparation and a rubber dam procedure. 
 
You asked the Plan to pre-approve the requested dental services. You say that you are experiencing pain. The 
Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental 
canal preparation and a rubber dam procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Red Anodized color package for a power wheelchair 
 
 
You asked the Plan to pre-approve the color package. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is a deluxe feature and does not serve a medical purpose. 
 
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 a Red Anodized color package for a power wheelchair
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure. 
 
You asked the Plan to pre-approve Fluoroscopic guidance (77003), Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869), Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870), and moderate sedation services (99156). You say that insertion of the 
lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. The 
Plan denied your request. The Plan says there currently is no clinical indications for this technology. 
 
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 Fluoroscopic guidance (77003), 
Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869), Insertion of 
Interlaminar/Interspinous Process Stabilization/Distraction Device (22870), and moderate sedation services 
(99156). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the spinous process spacer device remains experimental. 
More research is needed to show safety and efficacy. It is not needed in this case. There is no documented 
spinal instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fluoroscopic guidance (77003), Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22869), Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870), and moderate sedation services (99156) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression 
spacer procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
gastric cancer. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. Keytruda is not 
FDA approved for the treatment of recurrent locally advanced or metastatic gastric or gastroesophageal 
junction adenocarcinoma in patients whose tumors express PD-L1 (CPS =1), as determined by an approved 
test, with disease progression on or after two or more prior lines of therapy including fluoropyrimidine- and 
platinum-containing chemotherapy, and if appropriate, HER2/neu-targeted therapy. 
 
The use of Keytruda in this case is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that the enrollee needs the power 
wheelchair with requested accessories. The Plan denied your request. The Plan says the denial of authorization 
for this wheelchair option is correct, because a power seat elevation feature is not covered. The Plan also says 
that the power wheelchair and all other requested accessories have been approved, so only the power seat 
elevation feature is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation feature.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional physical therapy visits. You say that that while you have 
made progress from the injury of your broken shoulder, you are not where you were before the injury. The Plan 
denied your request. The Plan says you do not meet criteria based on Medicare Local Coverage Article (LCA) 
A52775: Medical Necessity of Therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is 
not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for 
this condition and it appears that you have made improvements, you are driving and reaching more for daily 
tasks. Your functional level does not appear to require the unique skills of a professional therapist to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist or 
for physical therapy and occupational therapy, under the supervision of a therapist. You have been noted to be 
compliant in therapy and in recommendations and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain your current condition or to 
prevent or slow further deterioration. 
 
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 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and two extractions to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the consultation and extractions. You say that the general dentists you have 
seen have refused to do the extractions because the root of the tooth is long, and they do not have the right 
tools. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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 Plan's 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and two extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-level referral to a cardiologist. 
 
You asked the Plan to pre-approve the referral. You say that this provider has a very wide experience in 
treating all aspects of heart disease. The Plan denied your request. The Plan says a tertiary level of care is not 
needed at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance a second opinion by an additional board-certified cardiologist is reasonable and 
appropriate. This should be able to be accomplished safely and effectively by referral to an alternate in-network 
board certified cardiology provider, since dyspnea is a common symptom that board certified cardiology 
providers are adequately trained to evaluate and manage. Only if an alternate board-certified cardiologist is not 
available in-network would an out-of-network referral be 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary-level referral to a cardiologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you need to use oxygen during 
sleep and need a bed with an incline. The Plan denied your request. The Plan says the documentation does not 
support the medical need for this bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested semi-electric hospital bed is not shown to be medically reasonable and 
necessary in this case. Our physician reviewer found the patient's condition does not require position of the 
body in ways not feasible in an ordinary bed. The patient does not require frequent changes in body position. 
There is no need for immediate changes in body position. The patient's condition does not require special 
attachments that cannot be fixed and used on an ordinary bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for prostate 
cancer. 
 
You asked the Plan to pre-approve the PBRT treatments. You say that the use of PBRT will reduce radiation 
exposure to the bladder and rectum. Therefore, this is medically necessary. The Plan denied your request. The 
Plan says the criteria for this treatment have not been met in this case. 
 
The Plan follows Medicare rules. Medicare rules say that PBRT may be considered reasonable and necessary 
for prostate cancer in some cases based on the above guidelines.  
 
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 PBRT treatments. Our reviewer 
says that the documentation does not support that the requested PBRT is medically reasonable and necessary in 
this case. Our physician reviewer found the recently released ASTRO model policy for proton therapy states 
?In the treatment of prostate cancer, the use of PBT is evolving as the comparative efficacy evidence is still 
being developed. In order for an informed consensus on the role of PBT for prostate cancer to be reached, it 
essential to collect further data, especially to understand how the effectiveness or proton therapy compares to 
other radiation modalities.? and emphasizes the need to enroll patients on studies.  
 
The appeal mentions proton therapy reducing the bladder V50, V40 and V20 from 55% to 29%, 70% to 48% 
and 100% to 66% (respectively) with protons. With protons there was a reduction in rectal V50, V40 and V20 
from 32% to 25%, 48% to 29% and 90% to 40% (respectively). With protons there was a reduction in small 
bowel bag V25, V20 and mean dose from 49% to 20%, 59% to 23% and 23 to 12 Gy (respectively). Recent 
recommendations from group studies recommend that the 50% of the rectum should be exposed to no more 
than 60 Gy and the bladder no more than 65 Gy.  
 
Thus, both plans meet standard dosimetric constraints as would be expected with IMRT albeit without dose 
exposures >25 Gy provided for bowel. A clinically meaningful, plausible benefit from proton therapy was not 
shown in the case records, and it seems as though proton therapy is being offered for routine care, outside of a 
clinical trial. Proton therapy will always reduce normal tissue exposure but not always in a clinically 
meaningful manner. In order to establish medical necessity, a plausible clinical benefit should be demonstrated. 
Proton therapy for prostate cancer is not experimental but any potential benefit or detriment of proton therapy 
over standard IMRT for routine cases is an investigational issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PBRT treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT) for prostate cancer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One (J7325). 
 
You asked the Plan to pre-approve Synvisc One. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not tried conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via 
intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary 
when the patient has failed at least three months of conservative therapy. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has tried 
and failed conservative therapy as defined above.  Based on this information, we decided that Medicare rules 
for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-
approve Synvisc One (J7325).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support with tracheostomy care, suctioning, nebulizer treatments, telemetry, 
surveillance laboratory studies, tube feeding, wound care, and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 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.