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

 
We decided that the Plan does not have to pre-approve CardioMEMS HF System. 
 
You asked the Plan to pre-approve CardioMEMS HF System. You say that the device is medically necessary. 
The Plan denied your request. The Plan says there is no documentation the enrollee is enrolled in a clinical trial 
or registry per CMS criteria. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure.  Medicare 
coverage criteria are not met, since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CardioMEMS HF System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the service is medically necessary. The Plan 
denied your request. The Plan says a core buildup is not a covered service. 
 
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 a 
core buildup (D2950).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested drug 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 
documentation does support that the enrollee meets criteria for the requested drug. Our physician reviewer 
found the enrollee has non-small cell lung cancer. The enrollee has been stable on pembrolizumab since 2017 
and tolerating well. The requested drug is FDA approved for the enrollees diagnosis. The documentation 
supports that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
and crown - porcelain/ceramic, teeth #18 and #19 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says D2950 is not a covered benefit and you exhausted your 
benefit for D2740. 
 
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. Core buildup, including any pins when required (D2950) is not listed 
as a covered benefit with your plan. Furthermore, you exhausted your benefit for crowns because you had the 
same service provided for tooth #18 on April 20, 2016 and tooth #19 on March 21, 2019. Your contract states 
that D2740 is covered one (1) per tooth per sixty (60) months per patient. Therefore, we decided that the Plan 
does not have to pre-approve core buildup, including any pins when required (D2950) and crown - 
porcelain/ceramic, teeth #18 and #19 (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Palingen or promatrx, (stem cell injection) (Q4174). 
 
You asked the Plan to pre-approve the Palingen or promatrx,. You say that Amniotic Cell Therapy provides a 
multitude of benefits regarding healing. You respectfully request that the previously submitted claim be re-
evaluated and authorized. The Plan denied your request. The Plan says this procedure 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. The rules also say that experimental and investigational devices are not covered. 
 
We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the Palingen or promatrx, have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Palingen or promatrx, (stem cell injection) (Q4174).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the periodontal scalings and root planings (D4341) of the UR, UL, 
LR, and LL quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the correct documentation has been 
submitted multiple times to show that the deep cleaning is medically necessary. The Plan denied your request. 
The Plan says that the documentation does not demonstrate evidence of significant bone loss and/or 
radiographic root surface calculus on 4 or more teeth per quadrant that is required to qualify you for this 
procedure. 
 
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 the scalings 
and planings 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 the scalings and planings. Our reviewer 
says that the periodontal scalings and root planings meet coverage criteria. Our physician reviewer found on the 
basis of the abnormal periodontal pocketing and areas of observable bone loss, the criteria for coverage for 
periodontal scaling and root planing (D4341) in four quadrants have been met. 
 
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 the scalings and planings have been met. Therefore, we decided that the Plan 
has to pre-approve the periodontal scalings and root planings (D4341) of the UR, UL, LR, and LL quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee uses three or more 
injections of insulin daily. Based on this information, we decided that Medicare rules for coverage of the 
Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Continuous Glucose Monitor (CGM) (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 you appear to be improving and should not require more than 24 days of inpatient 
acute care services to become stable enough to transfer to a lower level of care, based on recent notes. You do 
not require services in the LTACH that are not available in the current setting. There are no services in the 
LTACH that you require that are not already available and covered in the current setting. Therefore, the 
LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may 
be considered soon. 
 
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 admission to a long term acute care hospital (LTACH).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has diagnoses of excess 
androgen and hirsutism. The Medicare-approved compendia do not support the use of Lupron Depot for these 
diagnoses. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan of extremity veins 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 that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services are covered when they meet criteria and 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 services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the study in question. A vascular malformation on the surface may represent more extensive communication to larger vascular structures below. These may have significant implications if the enrollee is planning lower extremity surgery. Duplex ultrasound is a key noninvasive total to examine superficial vascular lesions especially in the initial outpatient setting. The study would help characterize the lesion and demonstrate its vascularity and involvement of other major vascular structures.

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 been met. Therefore, we decided that the Plan has to pre-approve a duplex scan of extremity veins 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of breast implant surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the documentation provided, the initial implants appear to have been placed for cosmetic 
reasons. Examination detail does not document findings of capsular contracture or disfigurement, as well as 
evidence of significant macromastia. There is no evidence of a concern for siliconoma or granuloma. There is 
no evidence of a broken or failed implant. There has not been concern with interference with a diagnosis of 
breast cancer documented. Recent mammogram and examination did not note suspicious concerns. Finally, the 
enrollee has not been documented with capsular contracture with disfigurement. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of breast implant surgery for the enrollee.
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 going to a LTACH is very beneficial for 
the enrollee's condition. The Plan denied your request. The Plan says the LTACH admission 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 he is currently receiving care. Our reviewer 
found that 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. Our physician reviewer also found 
that 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
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 step therapy requirement 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee pain due to 
unilateral primary osteoarthritis of the right knee. He has not tried and failed the Plan's required drugs of 
Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less 
effective; therefore, Supartz FX is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health services. 
 
You asked the Plan to pre-approve the home health services. You say that the additional home health services 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the additional home health visits are not medically necessary. Our physician reviewer found the 
enrollee's condition is stable and chronic and the patient does not require ongoing skilled professional nursing 
care and there is no evidence of complex wound care or other skilled nursing needs. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you need to be evaluated to ensure you're in 
good health. The Plan denied your request. The Plan says you are on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The file shows that you are under the Medicare hospice benefit. Therefore, we decided that the Plan does not 
have to pre-approve a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Prolia (J0897). 
 
You asked the Plan to pre-approve a tier exception for Prolia. You say that the tier exception 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. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a tier exception for Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical 
pump. 
 
You asked the Plan to pre-approve a NPWT electrical pump. You say that the item is 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 an NPWT pump and supplies will be denied as not 
reasonable and necessary under certain circumstances. 
 
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 NPWT electrical pump. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found coverage criteria have not been met 
to support the continued use of negative pressure wound therapy. The documentation indicates that the enrollee 
began negative pressure wound therapy on April 23, 2020. The coverage criteria states that NPWT will be 
considered not medically necessary if 4 months (including the time NPWT was applied in an inpatient setting 
prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound. 
 
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 NPWT electrical pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump.