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

 
We decided that the Plan does not have to pre-approve a pneumatic compression 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 there was no documentation submitted with the appeal that showed serial measurements 
during treatment interventions. 
 
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 the documentation does not reveal objective findings of persistence of chronic and severe lymphedema 
as identified by the documented presence of at least one of the following clinical findings: 
 
 
 Marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica, deformity 
of elephantiasis, skin breakdown with persisting lymphorrhea, or detailed measurements over time confirming 
the persistence of the lymphedema with a history evidencing a likely etiology unresponsive to other clinical 
treatment over the course of a required four-week trial with detailed measurements of outcome. 
 
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 a pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray 
(D0220) provided on June 11, 2020. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the services would not be 
covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. 
The Plan also says that periapical x-ray is not listed as 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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq (J9022) and Paclitaxel Proteinbound Particles 
(J9264). 
 
You asked the Plan to pre-approve the Tecentriq and Paclitaxel Proteinbound Particles. You say that the 
enrollee has missed treatment. The Plan denied your request. The Plan says the enrollee does not meet the 
clinical criteria for coverage. 
 
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 the Tecentriq and Paclitaxel 
Proteinbound Particles. Our reviewer says that Tecentriq and Paclitaxel Proteinbound Particles are not 
medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of 
Tecentriq (J9022) and Paclitaxel Proteinbound Particles (J9264) is not Food and Drug Administration (FDA)-
approved for the enrollee's diagnosis. Our reviewer also found that the use of these drugs 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 the Tecentriq and Paclitaxel Proteinbound Particles have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Tecentriq (J9022) and Paclitaxel 
Proteinbound Particles (J9264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement 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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that DME repairs are covered for irreparable damage 
or when the equipment exceeds the reasonable lifetime period. 
 
We looked at the file and Medicare rules. The file shows that the enrollee's current PWC is not more than five 
years old or irreparably damaged. The current chair can also accommodate the additional requested accessories. 
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 a replacement power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on with respiratory failure secondary to COVID-19. He was treated with oxygen 
and intubation was not required. 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. 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lactulose breath testing. 
 
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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that lactulose breath hydrogen is excluded from coverage. 
 
We looked at the file and Medicare rules. The services at issue are lactulose breath hydrogen testing. These 
services are excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-
approve lactulose breath testing.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from April 18, 2020, 
to April 22, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that care can be given at a different level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission, the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from April 18, 2020, to April 22, 2020.  
 
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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not covered 
benefits. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62323). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when 
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 injections. Our reviewer says that 
the injections are not medically necessary. Our physician reviewer found there is no documentation indicating 
that the member's pain failed to improve following a 4 week trial of standard treatment methods such as rest, 
and medications. There is no role for a series of scheduled epidurals. Response to each epidural should be 
determined prior to determining the value of a subsequent epidural. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexabed. 
 
You asked the Plan to pre-approve Flexabed. You say that you believe this bed will enhance your health for the 
rest of your life. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because this bed cannot be rented and used by successive patients and would be useful in the absence of illness 
or injury; therefore, it does not meet the Medicare definition of Durable Medical Equipment (DME). 
 
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 Flexabed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. You say that you are disappointed with the denial 
and request reconsideration. You have a lot of back pain while doing regular activities. Walking and sitting is 
becoming hard and painful. The Plan denied your request. The Plan says the medical necessity criteria was not 
met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic services Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found besides a limited past history, there is no evidence of a complete present history, 
complete examination findings, including, but not limited to, findings related to a subluxation, quantifiable 
measures of range of motion and strength, orthopedic and neurological findings, palpation and postural 
findings or any evidence of any examination findings to support the necessity of chiropractic treatment. The 
submitted x-ray of March 12, 2020 of the lumbosacral spine reveals no findings that support chiropractic 
treatment, with no evidence of a subluxation.  
 
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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the chiropractic services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
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 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer remains experimental. More research is needed to show safety and efficacy of the 
device. 
 
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
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. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy requirements. 
 
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 
enrollee has not met step therapy requirements for coverage of Prolia. Our physician reviewer found that the 
enrollee has not tried and failed the required drug. Based on the medical records provided there is no indication 
that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 patient appears to be improving but requires additional acute care services for less 
than 25 days, which can safely be completed at the current facility. The patient does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer to a lower level  of care may be 
considered with more time at the current facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral formula (HCPCS B4150 and B4152) provided to the 
enrollee on April 21, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted medical records do not support the units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
HCPCS B4150: 
 
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins 
and minerals, May include fiber, administered through an enteral feeding tube, 100 calories = 1 unit 
 
HCPCS B4152: 
 
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact 
nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, May include fiber, administered 
through an enteral feeding tube, 100 calories = 1 unit 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review has determined that the records do not support that 201 units of B4150 were supplied. The records do 
not support that 464 units of B4152 were supplied. 
 
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 pay for enteral formula (HCPCS B4150 and B4152) provided to the enrollee on April 21, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato 56MG (28 MG x2 nasal spray. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the member must also try three (3) different antidepressants with three different 
mechanisms of action for at least twelve (12) weeks each. The Plan states the information from the records 
shows that the member tried duloxetine, but they were not able to confirm that the member has tried two (2) 
other drugs for 12 weeks. 
 
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 the medication. Our physician reviewer 
found the Plan requires a trial of three (3) different antidepressants with three different mechanisms of action 
for at least twelve (12) weeks each before they will approve the requested drug. In this case, information from 
the provider shows the enrollee has tried duloxetine and sertraline, but we were not able to confirm that you 
have tried another generic drug for 12 weeks each. The review indicates that the patient has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Spravato 56MG (28 MG x2 nasal spray.