Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment by injection (96372) with Pyridoxine (J3415), neuromuscular reeducation (97112), and vasopneumatic device therapy (97016).
You asked the Plan to pre-approve treatment by Pyridoxine injection, neuromuscular reeducation, and vasopneumatic device therapy. You say that the requested services are medically necessary for you. The Plan denied your request. The Plan says rules for pre-approval of the requested services have not been met because they are considered experimental/investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve treatment with Pyridoxine injection, neuromuscular reeducation, and vasopneumatic device therapy. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that you sustained a Traumatic Brain Injury and now have small fiber neuropathy. However, the requests for Pyridoxine, neuromuscluar stimulation and a vasopneumatic device are experimental/investigational for chronic pain due to small fiber neuropathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment with Pyridoxine injection, neuromuscular reeducation, and vasopneumatic device therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment by injection (96372) with Pyridoxine (J3415), neuromuscular reeducation (97112), and vasopneumatic device therapy (97016).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Hyalgan is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Hyalgan.
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 enrollee does not meet the criteria for a step therapy exception for Hyalgan. Our physician reviewer found the enrollee is not currently receiving Hyalgan. The enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The prescriber has indicated that there is no intolerance or contraindication to these preferred drugs. 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 use of Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that your current shower chair is beginning to 
breakdown. The Plan denied your request. The Plan says a shower chair is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at an alternate 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 an abdominal binder. 
 
You asked the Plan to pre-approve an abdominal binder.. You say that you require the abdominal binder for 
pain. The Plan denied your request. The Plan says it is an item excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Over the Counter items are excluded from coverage.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an abdominal binder have not been met. Therefore, we decided that the Plan does not have to pre-
approve an abdominal binder.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
needs can be met at an alternate 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 they are currently receiving care. The 
documentation does not support that an additional 25 days of hospitalization are reasonably expected for the 
enrollee in this case. 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on Medicare guidelines and the information the Plan has about the enrollee's condition, the enrollee does not meet all of the requirements for coverage.
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 that the enrollee is a 68-year-old male who was admitted to the current acute care hospital with multiple fractures and acute respiratory failure related to an MVA. The enrollee was treated with a chest tube for hemothorax and required mechanical ventilation and trach placement. Weaning has been initiated and the enrollee is tolerating trach collar trial. No permanent feeding tube has been place. The enrollee appears to be improving and more stable but requires additional short-term acute care services including further weaning and more permanent feeding tube or advancement to oral feeding that can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental case management - care coordination 
(D9992) with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental case management with an out-of-network provider.. You say that 
your dentist knows your health history. The Plan denied your request. The Plan says you must use an in-
network provider in order for services to be 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental case management - care coordination (D9992) with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device 
for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published peer-reviewed literature that shows the request to be advantageous over 
conventional surgical techniques. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for 
Coflex lumbar interspinous compression device is not medically reasonable or 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex lumbar interspinous decompression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental item. You say that the partial denture that you received previously
is too small and does not fit well. You say that you went back for adjustments twice. You say that the denture
still pinches your gums. You say that you felt if you ate with them, then they would break. You say that the
plan should not pay for your previous denture because they were bad. You also say that you want new ones
from the new dental provider. The Plan denied your request. The Plan says partial dentures are covered once
every 5 years. The Plan also says that the frequency limit has been reached.
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 and dentures are a covered service, the
frequency limit of once every 5 years has been reached. The record shows that the Plan paid for the denture that
you received on January 15, 2021. Therefore, we decided that the Plan does not have to pre-approve a partial
lower denture (D5214).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of malignancy.
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 therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of radiotherapy to treat arthritis dates back many decades and is commonly practiced in Germany and other European countries. While radiotherapy is not commonly utilized for arthritis in the US, it is an effective treatment for which many US doctors (who would refer for radiation) are unfamiliar. However, it is an accepted standard for osteoarthritis that is resistant to less invasive therapies (i.e. medical management, steroid injections). Radiation for treatment-resistant osteoarthritis, based upon published literature and guideline statements (from Germany) would be considered to be furnished with accordance of accepted standards of care and therefore my decision is favorable. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy for the enrollee.
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 the So Clean device. 
 
You asked the Plan to pre-approve the device. You say that your CPAP machine is difficult to clean. The Plan 
denied your request. The Plan says this 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 the So Clean device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the criteria for SNF care has not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found although there are identifiable skilled therapy 
service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not 
require skilled nursing or therapy services on a daily basis and does not meet 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy provider 
for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says care must be received 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 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 physical therapy provider for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo/Yervoy combination therapy. 
 
You asked the Plan to pre-approve Opdivo/Yervoy combination therapy. You say that the requested 
Opdivo/Yervoy combination therapy is medically necessary. The Plan denied your request. The Plan says the 
requested Opdivo/Yervoy combination therapy 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 Opdivo/Yervoy combination therapy. 
Our reviewer says that the requested Opdivo/Yervoy combination therapy is not medically necessary. Our 
physician reviewer found the enrollee is diagnosed with metastatic non-small cell lung cancer. The requested 
use of Opdivo/Yervoy combination therapy is not FDA approved for 1st line therapy for the enrollee's 
diagnosis. The use of Opdivo/Yervoy combination therapy is not supported by any of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal in heavily pretreated 
patients who have progressed on prior PD-L1 therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo/Yervoy combination therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Opdivo/Yervoy combination therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental porcelain crown (D2752). 
 
You asked the Plan to pre-approve porcelain crown. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the requested 
tooth does not appear to have significant breakdown due to decay or trauma. 
 
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. The Plan covers porcelain 
crown when the services are medically necessary and reasonable.  
 
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 porcelain crown. Our reviewer says that 
the requested porcelain crown is not medically necessary. Our physician reviewer found you are requesting a 
crown for tooth #26. Tooth #26 is an anterior tooth that has only endodontic access in it and no other notable 
damage. The incisal edge is intact and there is no pathological destruction of the coronal structure. The proper 
type of restoration for this would be a composite filling to seal the endodontic access. There is an inadequate 
loss of structure to require the full coverage protection that a crown provides. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of porcelain crown have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dental porcelain crown (D2752).