Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a trigger point injection. 
 
You asked the Plan to pre-approve a trigger point injection. The Plan denied your request. The Plan says that 
this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a trigger point injection. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is a 76-year-old woman with chronic pain with multiple generators. She has 
tried physical therapy, chiropractic, acupuncture, massage, and TENS. She has tried several medications, but 
has had side-effects. She is currently taking CBD oil. The progress note supports a trigger point injection in the 
suprascapular area. There is no documentation that this is a frequent series of trigger point injections. The 
enrollee has a trigger point and the request is medically reasonable and 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 a trigger point injection have been met. Therefore, we decided that the Plan has 
to pre-approve a trigger point injection.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revlimid. 
 
You asked the Plan to pre-approve Revlimid. The Plan denied your request. The Plan says the enrollee's plan 
does not cover outpatient prescription drugs. 
 
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 Revlimid.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve fragmenting of kidney stone. 
 
You asked the Plan to pre-approve fragmenting of kidney stone. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve fragmenting of kidney stone. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee initially presented with abdominal pain that could be caused by 
kidney stones. The enrollee is currently asymptomatic. The treatment decision for asymptomatic renal stones 
should take into consideration a variety of relevant enrollee and stone factors; however, ultimately, a shared 
decision-making approach should be used. In the properly counseled enrollee, active surveillance or 
prophylactic surgical intervention may be appropriate. Recent studies have found that stone size is a significant 
predictor of need for future surgical intervention, with greater than 4 mm stones. As such, fragmenting of 
kidney stones (ESWL) is considered the standard of care for the treatment and is medically necessary and 
reasonable for this enrollee for this enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fragmenting of kidney stone have been met. Therefore, we decided that the Plan 
has to pre-approve fragmenting of kidney stone.
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 Supartz FX. 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 Supartz FX. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of Supartz FX. Our physician reviewer found 
that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. The 
documentation does not outline contraindications or reasons these medications were not considered. Without 
the support of the documentation, Supartz FX is not approved, as step criteria have not been 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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous 
glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
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. The record shows the enrollee is not insulin treated and only tests 
twice a day so the enrollee does not meet the Medicare coverage criteria for a CGM. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a tertiary level referral to a general surgeon. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information does not show a need for a tertiary level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found 
you have Barrett's esophagus and has been referred to tertiary care center for a highly specialized type of 
corrective procedure called TIF. It is not clear if the TIP is offered in the area and what level of competence of 
this new procedure is in the area. TIF is a highly specialized procedure that offers potentially less recovery 
time. A tertiary level of care is warranted 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 the referral have been met. Therefore, we decided that the Plan has to pre-
approve a tertiary level referral to a general surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator with non-invasive interfaces for the 
enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records submitted did not support the medical necessity required to 
approve the request. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has obstructive sleep apnea and obesity-hypoventilation syndrome, which are not covered diagnoses for a home 
ventilator. The appropriate treatment for these conditions in CPAP or BiPAP. The enrollee has not failed 
BiPAP; the enrollee improved clinically in the hospital while on BiPAP. It is not reasonable to expect that the 
pCO2 would correct completely to normal over a few days during an acute episode of respiratory failure. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator with non-invasive interfaces for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
genicular blocks for osteoarthritis is considered an experimental/investigational procedure. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of primary osteoarthritis of both knees. She describes pain with 
walking, squatting and weight bearing, along with weakness, popping and catching. The exam shows swelling, 
tenderness, and crepitus, pain on initiation of movement, and extreme limitation of ROM. The x-rays of both 
knees showed advanced bicompartmental degenerative change involving medial tibiofemoral joint space and 
patello-femoral articulation with no fracture. Genicular nerve blocks and genicular nerve ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral genicular nerve blocks.
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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested 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 enrollee is currently on pressure support with chest x ray showing persistent 
pulmonary opacities with improved alveolar opacity and small pleural effusion. He requires establishment of 
long-term method of nutritional support. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. 
 
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 a duplex scan. 
 
You asked the Plan to pre-approve a duplex scan.. The Plan denied your request. The Plan says a duplex scan is 
not medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that duplex scans are covered for the above indications. 
 
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 duplex scan.. Our reviewer says that 
the requested duplex scan is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has hypertension and an episode of syncope. There are no reports of localizing neurologic symptoms 
with the episode and no prior TIA or stroke. There is no known carotid or cardiovascular disease. The LCD 
rules state that carotid duplex scanning is necessary for syncope only when there are signs and symptoms 
consistent with carotid artery disease or insufficiency. In the absence of localizing neurologic signs associated 
with the syncopal episode, a carotid bruit or history of TIA, stroke or known carotid disease, a carotid duplex 
scan is not medically necessary and reasonable based on the CMS LCD coverage criteria. 
 
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 duplex scan. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network gastroenterologist. 
 
You asked the Plan to pre-approve these services. You say that the enrollee reports no success from treatment 
with Plan providers. The Plan denied your request. The Plan says the services are available from network 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network gastroenterologist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Praluent Pen. 
 
You asked the Plan to pre-approve Praluent. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by the Part B plan. 
 
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 a Praluent Pen.  
 
Benefits for Praluent 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 Digoxin. 
 
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 self-administered drugs are not covered. 
 
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 Digoxin.  
 
Benefits for these services 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 Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found you have anemia. The documentation does not support that you have tried and failed the 
required drug Retacrit. The documentation does not support that the Plan's required drug would likely be less 
effective an/or likely have adverse effects for you. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to provide Botox. 
 
You asked the Plan to provide injection, OnabotulinumtoxinA (J0585). You say that you want the enrollee to 
be treated with this drug. The Plan denied your request. The Plan says there are not enough studies showing 
that this medication will improve health outcomes for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to provide injection, OnabotulinumtoxinA (J0585). 
Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found 
though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, 
there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of 
gastric emptying study in patients with gastroparesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection, OnabotulinumtoxinA (J0585) have not been met. Therefore, we 
decided that the Plan does not have to provide Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says a CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee 
was found to have a 7mm calcified nodule on chest CT scan on August 3, 2017. The presence of homogeneous 
calcium indicates this is a granuloma, and therefore benign, and follow-up would not be indicated. A lack of 
growth or change has been demonstrated over a period of 3 years. No further imaging follow-up of this nodule 
is indicated. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the chest.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the enrollee has been on this 
medication with improved function and activities of daily living. 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 Hydrocodone-
Acetaminophen.  
 
Benefits for Hydrocodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.