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

 
We decided that the Plan does not have to pre-approve Ozempic injection 2 mg/1.5 ml. 
 
You asked the Plan to pre-approve the Ozempic injection. You say that the requested injection is medically 
necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic injection 2 mg/1.5 
ml.  
 
Benefits for the Ozempic injection may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that per the enrollee's treating physician, the 
enrollee meets the medical necessity outlined in the criteria. The Plan denied your request. The Plan says 
Vertiflex is investigational and experimental, and the enrollee is not receiving this device as part of a Medicare 
covered clinical trial. 
 
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 at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 Breathe Non-invasive Open Ventilation 
System (NIOV). 
 
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 separately covered. 
 
The Plan must follow Medicare rules. Medicare rules say that all oxygen accessories and supplies are included 
in the monthly rental. 
 
We looked at the file and Medicare rules. The requested item is not a home ventilator but an oxygen equipment 
accessory. Coverage cannot be separately approved for these services. 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 Life2000 Breathe Non-invasive Open Ventilation System (NIOV).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole Sodium. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole Sodium.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve lower extremity MRI. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the MRI is not medically necessary and reasonable in this case. 
 
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 lower extremity MRI. Our reviewer 
says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the 
enrollee is a 65-year-old female with right leg pain. There is no specific clinical rationale for the requested MRI 
of the lower extremity. There is no documentation that shows any physical therapy, chiropractic, or home 
exercise programs were done in the last 6 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity MRI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lower extremity magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve renew rectal insert, incontinence supply, (A4337). 
 
You asked the Plan to pre-approve the rectal inserts. You say that you feel that these inserts are medically 
necessary for your health, hygiene and quality of life. The Plan denied your request. The Plan says rectal inserts 
are not a covered benefit. 
 
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 the rectal inserts have not been met. Therefore, we decided that the Plan does not have to pre-
approve renew rectal insert, incontinence supply, (A4337).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 3 and 6. 
 
You asked the Plan to pre-approve the dental services. You say that the crowns for teeth # 3 and 6 are 
medically necessary. The Plan denied your request. The Plan says porcelain crowns are not listed as covered 
services. 
 
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 porcelain crowns are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
porcelain crowns (D2740) for teeth # 3 and 6.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lower extremity prosthesis, not otherwise specified 
(L5999). 
 
You asked the Plan to pre-approve the prosthesis. You say that the enrollee's current mechanical knee 
resistances are lacking in proper response and he has exceeded the function of this knee. You request review of 
this pre-authorization request and overturn the denial. The Plan denied your request. The Plan says there should 
be no separate billing, and there is no separate payment for a component or feature of a microprocessor knee 
other than the items described by the all-inclusive HCPCS codes. 
 
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 the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Lower extremity prosthesis, not otherwise specified (L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoes with custom orthotics. 
 
You asked the Plan to pre-approve custom shoes with custom orthotics. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom shoes with custom 
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. 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 (K0553, K0554).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional mileage allowance for transportation 
services (A0170). 
 
You asked the Plan to pre-approve an additional mileage allowance for transportation services. You say that 
you cannot find any other providers within a 75-mile limit. The Plan denied your request. The Plan says your 
benefit only allows 60 one-way trips with each one-way trip not exceeding 75 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 75 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 105 miles away from your residence. The Plan only covers distances up to 75 miles. Therefore, we 
decided that the Plan does not have to pre-approve an additional mileage allowance for transportation services 
(A0170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brilinta. 
 
You asked the Plan to pre-approve Brilinta. You say that the enrollee is already established on the medication. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Brilinta.  
 
Benefits for Brilinta may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia 250mg vial 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 no dispensing or administration plan has been provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orencia 250mg vial for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan 
denied your request. The Plan says the requested Zilretta is 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 Zilretta. Our reviewer says that the 
requested Zilretta is not medically necessary. Our physician reviewer found the enrollee was being treated for 
unilateral primary osteoarthritis, right knee and unilateral primary osteoarthritis, left knee. Enrollee presented 
with bilateral knee pain. She walks with a limp. The right knee pain is generally around the entire knee. The 
pain at its worst is moderate. The pain is intermittent and are increased with activities. Associated symptom is 
stiffness. She feels that flexion and extension are decreased. Exam reveals bilateral knee motion of 3-110 with 
1+ effusion. Tenderness is noted in the medial joint line on McMurray?s testing. There are palpable 
osteophytes. However, there is limited published (large volume-long term) peer-reviewed literature that shows 
the request to be an effective and/or safe treatment. In particular, repeat of such injections have not been 
concluded to be safe and effective. 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 
Zilretta 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right side radiofrequency ablation of the lumbar spine.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is only covered under certain medical indications. The file shows that radiofrequency ablation for L3-4 and L4-5 were requested on the right side. We looked at the file and Medicare rules. The medical records provided show that previous radiofrequency services provided 0% relief. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve right side radiofrequency ablation of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy (97140) provided October 5, 2020. 
 
You asked the Plan to pay for the manual therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records show the services were provided by a massage therapist 
under a Nurse Practitioner's supervision. Services by massage therapists are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for manual therapy (97140) provided October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096). 
 
You asked the Plan to pre-approve the sacroiliac joint 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 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 sacroiliac joint injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has already had 4 sets of sacroiliac joint injections in the past 8 
months. The additional injections are excessive and exceed the standard 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 the sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing for 4 or more teeth per 
quadrant (D4341) for the upper left and upper right quadrants, and a porcelain fused to noble metal crown 
(D2752) for tooth # 11. 
 
You asked the Plan to pre-approve the dental services. You say that you really need a crown for your canine 
tooth. The Plan denied your request. The Plan says the provided x-rays do not show that you have at least 4 
teeth that need treatment. The Plan says that your tooth has to have a lot of tooth missing from a cavity or have 
a lot of damage from being broken. The x-rays your dentist sent do not show this, so the crown is not medically 
necessary. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested services are not medically necessary. Our physician reviewer found the provided records 
indicate there are 2 teeth in the upper right quadrant and 3 teeth in the upper left quadrant. The requested code 
of D4341 applies to quadrants in which there 4 or more teeth present that are periodontally involved. As these 
quadrants have less than the requisite number of teeth, the code used is inappropriate and not considered 
medically necessary. The reviewer also found that the provided records show that tooth # 11 has no or minimal 
breakdown of the coronal structure and was approved for endodontic therapy. The reviewer found that after 
endodontic treatment is completed, there would only be the access opening to restore. Therefore, the reviewer 
found that a crown for tooth # 11 is not medically reasonable or necessary either. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve scaling and root planing for 4 or more teeth per quadrant (D4341) for the upper left 
and upper right quadrants, and a porcelain fused to noble metal crown (D2752) for tooth # 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that the request for continued 
inpatient hospital care is medically necessary. The Plan denied your request. The Plan says the request for 
continued inpatient hospital care 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 continued inpatient hospital care. Our 
reviewer says that the request for continued inpatient hospital care is not medically necessary. Our physician 
reviewer found the review indicates that the enrollee is diagnosed with end stage renal disease on dialysis; his 
condition was complicated with calciphylaxis and encephalopathy, he had complex hospital course and 
required to be switched to hemodialysis (HD) from peritoneal dialysis (PD), he had bilateral lower extremity 
(BLE) wounds without adequate response to wound care. He requires maximum assistance with feeding and is 
not a candidate for percutaneous endoscopic gastrostomy (PEG) tube. 
 
Per the reviewed documentation, he is alert and oriented, and hemodynamically stable. The review indicates 
that the enrollee is medically stable; the requested continued inpatient hospital care is not medically reasonable 
and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued inpatient hospital care.