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

We decided that the Plan does not have to pay for positioning wheelchair back cushion (E2620) expandable 
controller harness (E2313), electronic connection between two or more power seating system motors (E2311) 
and expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (E2377) provided June 16, 2020. 

You asked the Plan to pay for the cushion and electronic upgrades. You say that the records The Plan denied 
your request. The Plan says the medical records provided will show proof of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cushion and electronic upgrades. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal that the patient requires other types of 
proportional input devices or non-proportional input. The enrollee does not need to operate 3 or more powered 
seating actuators through the drive control, a separate display, other electronic devices or an attendant control. 
The enrollee's upper extremity strength and function are sufficient for the patient to control any power options 
through their own individual switches. 
 
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 cushion and electronic upgrades have not been met. Therefore, we decided 
that the Plan does not have to pay for positioning wheelchair back cushion (E2620) expandable controller 
harness (E2313), electronic connection between two or more power seating system motors (E2311) and 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (E2377) provided June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT Code 63650 X2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found the patient does NOT have an evidence-based indication for a SCS trial. The patient has the diagnosis of 
multiple sclerosis noted in one progress note but not others. The requested procedure 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 
X2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Epidural injection (62264). 
 
You asked the Plan to pre-approve an Epidural injection. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Epidural injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has not received evidence based therapies available. This proposed 
procedure is considered experimental/investigational and therefore, is deemed medically unreasonable and 
unnecessary. 
 
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 Epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Epidural injection (62264).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daratumumab (J9145). 
 
You asked the Plan to pre-approve Daratumumab. You say that the medication is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Daratumumab. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found the documentation does not support 
that the requested use of Darzalex is medically reasonable and necessary or safe and effective 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 Daratumumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Daratumumab (J9145).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional resin-based composites. 
 
You asked the Plan to pre-approve the additional resin-based composites. You say that this is your first time 
using the dental benefits. You say that you are entitled to use your services. The Plan denied your request. The 
Plan says your benefit is exhausted. 
 
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, you also have a maximum benefit of 
two fillings per year. The Plan already pre-approved two fillings, which exhausted your benefit. Therefore, we 
decided that the Plan does not have to pre-approve the additional resin-based composites.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the requested use of 
Avastin is not FDA-approved for the enrollee's diagnosis. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Avastin for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior tibial nerve stimulation (nerve stimulation 
treatments) (64566). 
 
You asked the Plan to pre-approve posterior tibial nerve stimulation. You say that you have determined that 
treatment with percutaneous tibial nerve stimulation is medically necessary and reasonable for the enrollee. The 
Plan denied your request. The Plan says the records show the enrollee has had 64 treatments. The maximum 
lifetime number Medicare allows is 45. This request is not medically necessary as the enrollee has had 
exceeded the maximum allowed. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of posterior tibial nerve stimulation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve posterior tibial nerve stimulation (nerve stimulation treatments) (64566).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical/thoracic facet joint neurolysis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no spine pain. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnostic blocks should be interpreted as negative, as they did not achieve 80% pain relief, which is 
the standard in the literature and the LCD. The requested procedure 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical/thoracic facet joint neurolysis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of intraosseous basivertebral nerve, first two 
vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (CPT Code C9752) and 
unlisted procedure, spine (CPT Code 22899). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure remains experimental. More research is needed to show safety and 
efficacy. 
 
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 destruction of intraosseous basivertebral nerve, first two vertebral bodies, including 
imaging guidance (e.g., fluoroscopy), lumbar/sacrum (CPT Code C9752) and unlisted procedure, spine (CPT 
Code 22899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and extraction. You say that you must have two extractions 
for further work to be done. The Plan denied your request. The Plan says services must be performed by a 
participating general dentist. 
 
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 when received by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve the consultation and extraction to be provided by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that the enrollee has been taking an oral biophosphonate, Fosamax, for 7 years. You say that the enrollee's bone density has worsened. You also say that Reclast is another biophosphonate and is not appropriate for the enrollee as it is the same class of drug that she failed. The Plan denied your request. The Plan says the criteria has not been met for coverage.

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 Prolia. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the documentation does not support a history if an osteoporotic fracture or previous treatment, contraindication, or intolerance to both oral bisphosphonate drug and zoledronic acid. The reviewer found that step therapy, as outlined by the plan, requires both be trialed or documentation of a contraindication. The reviewer found that without the support of the documentation, Prolia has not met the criteria for step 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric oxygen (HBO) therapy (99183). 
 
You asked the Plan to pre-approve HBO therapy. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 

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 HBO therapy. Our reviewer says that 
the services are medically necessary. Our physician reviewer found review of the submitted documentation 
does not include updated medical records. There is no documentation of current wound evaluation, 
documentation of the sessions completed, or current plan of care. Medicare guidelines are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyperbaric oxygen (HBO) therapy (99183).
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 not able to take care of yourself. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (CPT Code: G6002, 77523, 
77525). 
 
You asked the Plan to pre-approve the proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not 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 proton beam therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per NCCN, radiation compendia proton beam is not approved. Our physician says to 
consider EBRT or brachytherapy. 
 
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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (CPT Code: G6002, 77523, 77525).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary to diagnose where the 
pain is. The Plan denied your request. The Plan says it is too soon for more shots to be considered 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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee did not achieve greater than 80% pain relief from the first diagnostic medial branch block, 
therefore, the request 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat facet joint injection for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health; long-term care residential (non-acute 
care in a residential treatment program where stay is typically longer than 30 days), with room and board, per 
diem (CPT Code T2048 x30). 
 
You asked the Plan to pre-approve the services. You say that the resident stay is to help improve your well-
being. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
Payment cannot be made to a provider not enrolled. The request is for a residential psychiatric treatment 
facility. This provider type is not recognized by Medicare and cannot enroll in the program. Therefore, we 
decided that the Plan does not have to pre-approve behavioral health; long-term care residential (non-acute care 
in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem 
(CPT Code T2048 x30).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, a special kind of picture of the  tissue in your 
body (CPT Code 76390). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says research studies have not shown that the requested study is helpful for the member's 
problem (condition). 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
the enrollee has a history of multiple sclerosis and had MRI of the brain on October 10, 2020, showing interval 
increase in the size of a lesion of the corpus callosum and no new lesions. The requested MRI spectroscopy 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, a special kind of picture of the  tissue in your body (CPT Code 76390).