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

 
We decided that the Plan does not have to pre-approve MRI, orbit, face, and/or neck; without contrast 
material(s) (CPT Code 70540) and the MRI, brain (including brain stem); without contrast material (CPT Code 
70551). 
 
You asked the Plan to pre-approve the MRI's. You say that the services are medically necessary. The Plan 
denied your request. The Plan says outreach was made with provider to request the findings of the brain MRI in 
2017, the provider did not submit the findings nor did they submit a letter of medical necessity for the neck 
MRI. The Plan states that medical necessity criteria was not met for either MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRI's have not been met. It was determined that no order from the provider was submitted and 
medical necessity criteria was not met. Therefore, we decided that the Plan does not have to pre-approve MRI, 
orbit, face, and/or neck; without contrast material(s) (CPT Code 70540) and the MRI, brain (including brain 
stem); without contrast material (CPT Code 70551).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 for the enrollee. 
 
You asked the Plan to pre-approve the viscosupplemental agent. You say that this is medically necessary. The 
Plan denied your request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc and 
don't require prior authorization. 
 
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 viscosupplemental agent. Our 
reviewer says that the requested viscosupplemental agent is not medically reasonable or necessary, and does 
not meet the step therapy criteria. Our physician reviewer found the enrollee has not trialed viscosupplemental 
treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. 
The documentation does not outline contraindications or reasons these medications were not considered. 
Without the support of the documentation, Gelsyn-3 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 the viscosupplemental agent have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Gelsyn-3 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hand controls for a car. 
 
You asked the Plan to pre-approve hand controls for a car. You say that the member's health is at jeopardy 
because at any moment in time while driving they could stop feeling their lower body from the way down. The 
Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan. 
 
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 hand controls for a car.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a cervical MRI. 
 
You asked the Plan to pre-approve a cervical MRI. You say that the requested cervical MRI is medically 
necessary. The Plan denied your request. The Plan says that the requested cervical MRI is not medically 
necessary. 
 
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 a cervical MRI. Our reviewer says that 
the requested cervical MRI is medically necessary. Our physician reviewer found the enrollee is with a history 
of TMJ with prior procedure with significant symptoms and has been referred to OMFS (Oral maxillo-facial 
surgeon). The enrollee has trouble eating and symptoms with chewing and yawning. The enrollee is a surgical 
candidate and needs MRI for diagnostic purposes and whether to see if surgery can be of benefit in this 
symptomatic patient. 
 
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 cervical MRI have been met. Therefore, we decided that the Plan has to pre-
approve a cervical MRI.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the neck. 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that the requested CT scan of the neck is 
medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the neck 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 of the neck. Our reviewer 
says that the requested CT scan of the neck is medically necessary. Our physician reviewer found the enrollee 
is with a significant medical history involving a T4aN0M0 squamous cell carcinoma. The enrollee is status post 
tracheostomy, bilateral selective neck dissection levels 1 through 4, composite resection of the anterior 
mandible, floor of mouth and anterior lateral mandible, wedge resection of the lip and radial forearm free flap 
reconstruction on 8/3/17 for T4aN0M0 squamous cell carcinoma of the anterior floor of mouth. Per the NCCN 
guidelines for head and neck cancer 2.2020, page IMG-A 4/4 states that yearly imaging may be warranted to 
look at areas not accessible to direct visualization. In this case, the requested CT scan of the neck 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 CT scan of the neck have been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan of the neck.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of hypertension, atrial fibrillation and an aortic valve replacement who presented to the acute 
hospital on 09/19/2020 with a fall and right hip fracture. She was treated in the hospital with orthopedic 
consultation and underwent an uncomplicated surgical repair of the fracture. She is weak and deconditioned 
and is working with physical and occupational therapy. She is walking 2 feet with a rolling walker with 
moderate assistance and is minimum to moderate assist for transfers and activities of daily living. She is 
medically stable. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern 
that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral branches of 
the sacroiliac (SI) joints. 
 
You asked the Plan to pre-approve the SI joint RFA procedure. You say that this treatment was helpful on the 
other side and should be allowed. The Plan denied your request. The Plan says medical research does not 
support this treatment. 
 
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 SI joint RFA procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this woman has chronic low back pain and sacro-ilitis. She had Right lateral 
branches S1-S4 RFA on April 22, 2020 with 95% pain relief. The request is for Left RFA of lateral branches of 
S1-S4. 
 
This procedure is considered experimental/investigational because of the wide variation efficacy in the peer-
reviewed literature. Therefore, the request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SI joint RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral branches of the sacroiliac (SI) 
joints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MitraClip surgery (Transcatheter Mitral Valve Repair).
You asked the Plan to pre-approve MitraClip surgery (Transcatheter Mitral Valve Repair). You say that the requested MitraClip surgery (Transcatheter Mitral Valve Repair) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested MitraClip surgery (Transcatheter Mitral Valve Repair).
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 MitraClip surgery (Transcatheter Mitral Valve Repair). Our reviewer says that the enrollee does not meet criteria for the requested MitraClip surgery (Transcatheter Mitral Valve Repair). Our physician reviewer found based on the records the enrollee has symptomatic severe mitral regurgitation with a severely deformed valve including marked annular calcification and very eccentric regurgitation. In this circumstance there is documented uncertainty about the suitability of MitraClip placement and also there is no documented prohibitive risk for mitral valve surgery. In fact, the documented surgical opinion states "a higher but acceptable risk of mitral valve surgery". In this setting of uncertain suitability for MitraClip placement and acceptable surgical risk coverage criteria for MitraClip placement is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MitraClip surgery (Transcatheter Mitral Valve Repair) have not been met. Therefore, we decided that the Plan does not have to pre-approve MitraClip surgery (Transcatheter Mitral Valve Repair).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you need to check your sugar a lot and have issues 
with using half of your body and your arm shakes a lot. This makes a regular monitor difficult to use. The Plan 
denied your request. The Plan says criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs may be covered when the above 
referenced criteria are met.  
 
Review of the records submitted does not clearly document the number of times your provider has ordered for 
blood sugar testing per day. The record shows that you do not currently inject insulin. Based on this 
information, the criteria for coverage of a CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacral lateral nerve branch blocks/sacral lateral nerve 
branch radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that there are articles that cite the effectiveness of this 
service. The Plan denied your request. The Plan says this 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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is still considered experimental/ investigational because of the wide variation of efficacy in the peer-
reviewed literature. Therefore, the request is considered not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacral lateral nerve branch blocks/sacral lateral nerve branch radiofrequency ablation for 
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara 90mg/mL syringes. 
 
You asked the Plan to pre-approve the Stelara. You say that this medication is necessary to treat the enrollee's 
psoriasis. The Plan denied your request. The Plan says this drug is to be picked up at a retail pharmacy meaning 
it cannot be covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Stelara 90mg/mL syringes.  
 
Benefits for the Stelara 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you do not have anyone 
that can take you to your appointments. The Plan denied your request. The Plan says you have used thirty-three 
(33) one-way transportation trips. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of thirty-six (36) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Any trips beyond the 
36 are not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary immediate denture (D5130). 
 
You asked the Plan to pre-approve the maxillary immediate denture. You say that the enrollee lost her dentures 
while she was in the hospital. You also say that the enrollee is unable to eat much now. The Plan denied your 
request. The Plan says this service exceeds the maximum count allowed. 
 
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, maxillary immediate denture (D5130) 
is limited to one procedure per lifetime. The record shows that the enrollee received a maxillary immediate 
denture (D5130) on August 13, 2017 and the enrollee's maxillary immediate denture (D5130) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary immediate denture 
(D5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2) and removable 
prosthodontic procedure (D5899). 
 
You asked the Plan to pre-approve the gingival irrigations and removable prosthodontic procedure. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
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 two 
gingival irrigations (D4921 x2) and removable prosthodontic procedure (D5899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 27, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reacher. 
 
You asked the Plan to pre-approve reacher. You say that you live alone and if you need to reach something on 
a top shelf you have no one to help you. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because this item is not primarily medical in nature and is a convenience 
item. 
 
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 reacher.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle CGM. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor.  
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose testing's every day and is insulin-treated with 
at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. The file shows that you are not insulin-treated at least three times per day nor do you 
have a CSII pump. Based on this information, we decided that Medicare rules for coverage of a Freestyle CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Continuous 
Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A battery backup is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a 
battery backup.