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

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you are in constant pain and do not 
want to just take medications for it. The Plan denied your request. The Plan says the procedure is only covered 
with less than 6 weeks of a condition where the bones are weak and at risk for fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is only covered under certain medical 
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 the requested services. Our physician 
reviewer found that you have a diagnosis of age-related osteoporosis with current pathological fracture. It is 
documented that your pain started 10 months ago after a fall that might have precipitated it. A magnetic 
resonance imaging (MRI) in June 2020, revealed a T12 compression fracture of 50 - 75%. The documentation 
does not support that you have an acute osteoporotic vertebral compression fracture, diagnosed by advanced 
imaging within 30 days. The records do not show the coverage criteria has been met for the requested 
procedure. 
 
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 a kyphoplasty procedure.
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) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870). 
 
You asked the Plan to pre-approve the services. You say that lumbar spinal stenosis is a treatable disease and 
the enrollee meets commonly accepted medical criteria supporting surgical intervention. The Plan denied your 
request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's 
health problem. 
 
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 device is experimental. More research is needed to show safety and efficacy. 
 
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) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vemlidy. 
 
You asked the Plan to pre-approve Vemlidy. You say that the medication is a better choice for the enrollee. The 
Plan denied your request. The Plan says Vemlidy to be administered at home is not covered under the Part B 
benefit. 
 
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 Vemlidy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar 
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, 
facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single 
or multiple levels, unilateral or bilateral; lumbar (CPT Code 0275T). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this procedure is not a covered benefit because this procedure in not being 
provided in the context of an approved Medicare clinical trial. 
 
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 procedure is experimental. More research is needed to show the safety and efficacy of the 
PILD procedure. It is not an acceptable option for this 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 
neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any 
method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; 
lumbar (CPT Code 0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has difficulty taking pills, 
and needs more long-term relief. The Plan denied your request. The Plan says there has not been sufficient 
published literature to show safety and efficacy. 
 
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 diagnosis of sacroiliitis, not elsewhere classified. The enrollee underwent 
L3-S1 lumbar fusion in 2019. Physical exam showed bilateral sacroiliac joint tenderness to palpation. The 
enrollee has low back pain. An MRI demonstrates significant stenosis primarily at the L2-3 level. It has not 
been demonstrated in the medical literature that radiofrequency ablation provides significant long-term benefit 
for those with sacroiliitis and low back pain. Therefore, the requested services are not considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq (atezolizumab) treatments. 
 
You asked the Plan to pre-approve the Tecentriq treatments. You say that although there has been minor 
progression, it is felt that this treatment is still helpful and should be continued until surgical options can be 
considered. The Plan denied your request. The Plan says criteria are not met for the requested drug. 
 
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 treatments. Our reviewer 
says that the requested medication is not considered medically reasonable and necessary. Our physician 
reviewer found the enrollee has a diagnosis of metastatic urothelial cancer. A CT scan on 9/25/2020 showed 
two small pulmonary nodules and lesions around the kidneys. Tecentriq is FDA-approved for the enrollee's 
diagnosis but not when there has been progression on this therapy. There is no support in the major drug 
compendia or CMS-approved journal for continued use with progression of disease. 
 
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 treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Tecentriq (atezolizumab) treatments.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approveXerava.You asked the Plan to pre-approveXerava. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says that the off-label use of the requested drug for the enrollee's condition is not medically accepted per Medicare rules and isn't covered based on available information.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 Xerava. Our reviewer says that the requested drug is medically reasonable and necessary for the enrollee in this case. Our physician reviewer found the enrollee has an active intra-abdominal infection and, more specifically, a peritoneal abscess that is actively draining pus. She has failed multiple IV antibiotics and it is medically appropriate to consider Xerava for this enrollee. It is not off label use, as it is indicated for complicated intra-abdominal infections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xerava have been met.Therefore, we decided that the Plan has to pre-approveXerava.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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that home care is not the level of support the enrollee 
needs. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or 
nursing services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our physician reviewer 
found that the enrollee needs contact guard assistance to supervision with transfers. She requires minimal 
assistance with some activities for daily living. She does not require the specialized skill of a skilled 
professional nurse to safely and effectively provide medically necessary in a SNF. She does not have complex 
wound care or other ongoing SNF level skilled nursing needs. Her functional level does not require the 
specialized skill of a qualified therapist to provide medically necessary treatment in a SNF.  
 
 
The enrollee does not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, 
this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services of home health/hospice aide in home health or 
hospice settings, each 15 minutes (CPT Code G0156). 
 
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 not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 physician reviewer 
found the records do not show that home health visits are needed to effectively provide treatment, care, and/or 
services in order to improve your level of function, or to establish/perform a maintenance program to maintain 
your level of function and/or prevent deterioration. The documentation does not support that you are 
homebound. Furthermore, the requested treatment of suprapubic catheter exchange is not appropriate for a 
home health aide, but rather that of a skilled nurse. The requested services do meet the definition of home 
health aide services per Section 50.2 and the request for  home health aide services is not reasonable and 
necessary to the treatment of your illness or injury by the skilled professional staff. 
 
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 services of home health/hospice aide in home health or hospice settings, each 15 minutes 
(CPT Code G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement air filters for an air cleaning device. 
 
You asked the Plan to pre-approve the air filters. You say that the enrollee requires this filtration due to the heat 
and fires which cause bad air quality. She has allergic reactions and has a low immune system. The Plan denied 
your request. The Plan says the requested equipment is not considered medical in nature. 
 
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. Medicare rules 
explicitly state that air cleaners are not primarily medical in nature. Therefore, we decided that the Plan does 
not have to pre-approve replacement air filters for an air cleaning device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an endobronchial valve procedure.
You asked the Plan to pre-approve the requested services. You say that the requested valve is an important treatment option for those who have failed more conservative interventions. The Plan denied your request. The Plan says that the requested service is experimental as there is no valid study comparing the endobronchial valve to the open lung reduction surgery.
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 requested services. Our physician reviewer found that the enrollee had placement of an earlier version of an endobronchial valve (EBV) in November 2019, with initial improvement, but the treated lobe has partially re-expanded, possibly due to dislodgement of the valves. Maximum medical management has failed to improve the enrollee's symptoms. It is, therefore, reasonable to remove the current valves and place the Zephyr valves. Bronchoscopic EBV is no longer considered experimental because multiple randomized controlled trials have shown benefit that justifies the risks of the procedure, primarily pneumothorax. While it is true that EBV placement has not been directly compared with surgical lung reduction, the controlled trials establish its benefits, which are comparable to those seen with surgical lung reduction, with less postoperative pain. Therefore, placement of the EBV as treatment for COPD and emphysema is considered reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve an endobronchial valve procedure.
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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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 may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Desoximetasone cream. 
 
You asked the Plan to pre-approve the Desoximetasone. You say that you would like reconsideration because 
this medication is medically necessary. The Plan denied your request. The Plan says this drug is not covered for 
the member's condition 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 Desoximetasone cream.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) in combination with 
carboplatin. 
 
You asked the Plan to pre-approve the Keytruda/carboplatin regimen. You say that this treatment would be 
beneficial. The Plan denied your request. The Plan says the enrollee has not had progression on current therapy 
and there is no literature support of the requested regimen for this enrollee's condition. 
 
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 Keytruda/carboplatin regimen. Our 
reviewer says that the requested combination therapy is not considered medically reasonable and necessary. 
Our physician reviewer found the enrollee has stage IIIC breast cancer diagnosed in April 2020 who had 
neoadjuvant treatment with paclitaxel. Weekly carboplatin and Keytruda is requested. This regimen is not 
FDA-approved for this condition. There is only literature support for use in neoadjuvant combination therapy. 
The requested treatment is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Keytruda/carboplatin regimen have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda (pembrolizumab) in combination with carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
You asked the Plan to pre-approve the requested nerve stimulation device. You say that this should be approved as it is medically necessary and will likely reduce the enrollee's pain. The Plan denied your request. The Plan says these devices are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.