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

 
We decided that the Plan does not have to pre-approve Evenity (J3111). 
 
You asked the Plan to pre-approve Evenity. You say that this is the only treatment option. The Plan denied 
your request. The Plan says no justification for additional doses has been provided. 
 
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 Evenity. Our reviewer says that the 
requested use of Evenity is not supported. Our physician reviewer found the effect of the requested medication 
decreases after twelve months, meaning treatment with the requested medication for longer than twelve months 
is not warranted. The enrollee has already used the requested medication for twelve 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity (J3111).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex surgery. 
 
You asked the Plan to pre-approve the Vertiflex surgery. You say that this procedure is medically necessary for 
the enrollee. The Plan denied your request. The Plan says there is a lack of evidence the Vertiflex procedure is 
safe and effective. 
 
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 Vertiflex surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
efficacy of the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex surgery.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you go to dialysis 3 days a week. The Plan 
denied your request. The Plan says you have used all of your transportation benefit. 
 
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 a maximum of 40 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. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 125mg Dofetilide capsules. 
 
You asked the Plan to pre-approve the Dofetilide. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this medication does not fall under 
the member's Medicare Part B benefits. 
 
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 125mg Dofetilide capsules.  
 
Benefits for the Dofetilide 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hemochromatosis mutation analysis panel.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines are not 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have severe liver fibrosis and an elevated ferritin level. One set of iron studies was within normal limits. As such, testing has yet to show that genetic testing for hemochromatosis is medically necessary or reasonable. 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 a hemochromatosis mutation analysis panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the medial branches 
bilaterally at L3-L4, L4-L5 and L5-S1. 
 
You asked the Plan to pre-approve additional RFA services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that only up to two bilateral levels are covered per 
session. 
 
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 RFA services. Our reviewer says that 
the documentation does not support that the services are medically reasonable or necessary. Our physician 
reviewer found the enrollee has chronic low back pain without radicular signs. The enrollee underwent two sets 
of diagnostic medical branch blocks at a total of six joints each time. This exceeds the utilization limits of the 
LCD. Only four joints may have RFA at one session. Therefore, only four joints are approved and meet the 
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 RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the medial branches bilaterally at L3-L4, L4-L5 and L5-
S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS insertion. 
 
You asked the Plan to pre-approve CardioMEMS insertion. You say that  The Plan denied your request. The 
Plan says this device is considered experimental and not proven to be effective. 
 
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 CardioMEMS insertion have not been met. Therefore, we decided that the Plan does not have to 
pre-approve CardioMEMS insertion.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Entyvio medication (J3380).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria for coverage of this medication.
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 this medication. Our reviewer says that the enrollee does not meet the criteria for coverage of this medication. Our physician reviewer found that the Plan requires either a trial of Remicade or Inflectra and Stelara as its step therapy criteria. In this case, it is indicated that the enrollee has not tried and failed, or has a contraindication to the Plan's required step therapy agents. The elements of the Plan's step therapy criteria are not satisfied. Therefore, the requested medication cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the Entyvio medication (J3380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Silver Sneakers Membership. 
 
You asked the Plan to pre-approve a Silver Sneakers Membership. You say that your physician advised you to 
exercise due to an Osteoporosis diagnosis. The center you usually go to has closed. You would like the Plan to 
cover a Silver Sneakers Membership. The Plan denied your request. The Plan says gym or Silver Sneakers 
memberships are not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The Plan's rules for coverage of gym benefits have not been met because the Plan does not cover gym or Silver 
Sneakers memberships. Therefore, we decided that the Plan does not have to pre-approve a Silver Sneakers 
Membership.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot inserts (L3000). You say that you recommend foot inserts to limit the enrollee's subtalar joint motion. 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 the enrollee does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested proton beam therapy is 
medically necessary. The Plan denied your request. The Plan says the requested proton beam therapy 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 proton beam therapy. Our reviewer says 
that the requested proton beam therapy is not medically necessary. Our physician reviewer found proton 
therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach.  Other treatment 
approaches (IMRT +/- IGRT) are also highly effective and well tolerated.  Thus, whether proton therapy 
affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of investigation 
and remains controversial.   
 
To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bi-PAP supplies (A7038, A7039) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the Bi-PAP supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says the items can be obtained from network providers and the cost-sharing will be the same when obtained in-network.
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve Bi-PAP supplies (A7038, A7039) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says insulin is not taken three times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are not noted to use insulin multiple times per day. You are not noted to use the results of blood 
glucose testing to adjust insulin dosing multiple times per day. As such, the use of a CGM is not shown to be 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator for a power wheelchair (E2300). 
 
You asked the Plan to pre-approve the seat elevator. You say that you require the power lift to help with some 
activities. The Plan denied your request. The Plan says seat elevators do not serve a primary medical purpose 
and is statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Seat Elevator (E2300) does not serve a primary 
medical purpose and is statutorily non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the seat elevator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a seat elevator for a power wheelchair (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for the approved surgery. 
 
You asked the Plan to pre-approve inpatient admission for the approved surgery. You say that the requested 
inpatient admission for the approved surgery is medically necessary. The Plan denied your request. The Plan 
says the requested inpatient admission for the approved surgery 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 inpatient admission for the approved 
surgery. Our reviewer says that the requested inpatient admission for the approved surgery is not medically 
necessary. Our physician reviewer found the enrollee is diagnosed with lumbar spinal stenosis without 
neurogenic claudication. The Plan approved an elective lumbar hemilaminectomy, medial facetectomy, and 
decompression. There is no medical need for inpatient admission. The surgery may be performed safely as an 
observational 48 hour stay. It is routine lumbar decompression surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for the approved surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient admission for the approved surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services. 
 
You asked the Plan to pre-approve the inpatient mental health services. You say that the continued inpatient 
mental health services are medically necessary. The Plan denied your request. The Plan says rules for coverage 
are no longer met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health services. 
Our reviewer says that the inpatient mental health treatment is not medically necessary. Our physician reviewer 
found this enrollee does not meet the criteria for continued treatment in an acute inpatient mental health 
treatment facility.  The enrollee can be treated in a lesser restrictive setting as he was not showing any suicidal 
or homicidal ideation, auditory or visual hallucinations, or aggression. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your mother needs additional rehabilitation, and you 
are concerned that she might have another stroke if rehabilitation is not continued. The Plan denied your 
request. The Plan says IRF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for weakness, gait and mobility problems, hemiplegia, and cardiac arrhythmia. The 
enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 'Ab Interno Canaloplasty' surgery for the enrollee. 
 
You asked the Plan to pre-approve 'Ab Interno Canaloplasty surgery'. You say that this surgery is medically 
necessary. The Plan denied your request. The Plan says Medical necessity has not been established. 
 
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 Ab Interno 
Canaloplasty surgery. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer 
found current evidence of efficacy is limited and consists of primarily two non-randomized studies and 
uncontrolled retrospective comparisons, with few quality randomized control trials. The evidence regarding 
'Ab Interno Canaloplasty' is insufficient to make this procedure a standard of care for the treatment of open-
angle glaucoma. We looked at this physician's review, the file, and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of this treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 'Ab Interno Canaloplasty' surgery for the enrollee.