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

We decided that the Plan does not have to pre-approve Gel-One knee injection services. 
 
You asked the Plan to pre-approve the Gel-One knee injection services. You say that you are having issues 
with your knee and that you are allergic to steroids and ibuprofen. You say that you are in dire need of the Gel-
One injections. The Plan denied your request. The Plan says the records do not show that the enrollee has tried 
all of the Plan's preferred medicines. 
 
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 Gel-One knee injection services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the plan 
requires a trial of drugs Durolance, Gelsyn and Euflexx before they will approve the requested drug. There is 
no evidence that you have tried and failed these required drugs. Our physician reviewer found that there is no 
documented reason why these required drugs would be less effective and/or likely to have an adverse effect for 
you. 
 
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 Gel-One knee injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Gel-One knee injection services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the EGD, flexible, transoral; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (CPT Code 43235). 
 
You asked the Plan to pre-approve the EGD. You say that you want to have this test to find out where you are 
losing blood from. The Plan denied your request. The Plan says you do not have a recent colonoscopy. 
 
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 EGD. Our physician reviewer found 
the presence of gastrointestinal bleeding is an indication which supports an EGD for diagnostic purposes when 
there is presumed chronic blood loss and iron deficiency anemia, when colonoscopy is negative. It is not 
documented that you have gastrointestinal bleeding, or that you have had a colonoscopy. 
 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the EGD, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or 
washing, when performed (CPT Code 43235).
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). 
 
You asked the Plan to pre-approve the services. You say that the procedure has been in use for five years, 
which disputes the determination that it is experimental. You state that since your back surgery in 2016 you 
have used epidurals and facet blocks with some relief. The Plan denied your request. The Plan says there are 
not enough scientific studies to show that inserting a device to open the narrowed space would be safe and 
effective for you. 
 
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 of the device. 
There is no instability present. The device is not needed. 
 
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).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission for the 
enrollee. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met. 
 
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found the medical records do not show the enrollee requires ongoing skilled nursing services with the 
specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound 
care or other ongoing SNF level skilled nursing need. The enrollee's high functional level does not require 
ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. The enrollee does not require inpatient SNF services beyond the last covered date. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP device (CPT Code E0601) and humidifier, 
heated, used with positive airway pressure device (CPT Code E0562). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says there is missing documentation that is needed to support the request for this CPAP. 
The Plan states the supporting documentation is over two (2) years old and not current. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The records do not show a current 
sleep study has been performed. Therefore, we decided that the Plan does not have to pre-approve CPAP 
device (CPT Code E0601) and humidifier, heated, used with positive airway pressure device (CPT Code 
E0562).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) to be added to therapy with 
carboplatin/Taxotere. 
 
You asked the Plan to pre-approve the Keytruda treatments. You say that this treatment would be helpful and 
should be approved. The Plan denied your request. The Plan says there is no support for this treatment regimen 
for the 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 treatments. Our reviewer 
says that the requested treatment is not considered reasonable and necessary in this case. Our physician 
reviewer found this review relates to a request to add Keytruda to ongoing chemotherapy with 
Carboplatin/Taxotere for a 66-year-old woman with metastatic triple negative breast cancer. The requested use 
of Keytruda is not FDA approved. The use is not supported in any of the CMS approved compendia. This 
reviewer did not find any supporting citations in a PubMed search. Without literature support, this treatment is 
not supported.  
 
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 treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda (pembrolizumab) to be added to therapy with carboplatin/Taxotere.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's ability to regain maximum function is 
in jeopardy if denied the inpatient rehabilitation benefit. You say that it is medically necessary and essential for 
the enrollee to participate in an inpatient rehabilitation program. The Plan denied your request. The Plan says 
services can safely be received in other settings. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require an intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Our reviewer says that care at the skilled nursing facility level is 
more appropriate. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient mental health treatment have not been met. Specifically, medical records were not 
provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided 
that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Imfinzi for the enrollee. 
 
You asked the Plan to pre-approve Imfinzi. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that that the use of this drug in the enrollee's case requires Imfinzi will be 
used as consolidation therapy for unresectable stage III disease, and there has been no disease progression after 
2 or more cycles of definitive chemoradiation. 
 
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 Imfinzi. Our reviewer says that Imfinzi 
is medically reasonable and necessary for the enrollee in this case. The use of Imfinzi is supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation supports that Imfinzi is safe and effective and otherwise reasonable and necessary for this 
enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Imfinzi. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have been met. Therefore, we decided that the Plan has to pre-approve 
Imfinzi for the enrollee.  
 
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 Esomeprazole capsules for the enrollee. 
 
You asked the Plan to pre-approve Esomeprazole under Medicare Part B. You say that this drug is medically 
necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole capsules for 
the enrollee.  
 
Benefits for Esomeprazole 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup for tooth #2 to be provided with an 
approved crown. 
 
You asked the Plan to pre-approve the core buildup. You say that you need this core buildup as part of your 
crown and you are not able to afford the cost of the service, even with the discount. The Plan denied your 
request. The Plan says your benefit does not provide coverage for core buildups. 
 
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 a 
core buildup for tooth #2 to be provided with an approved crown.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto. 
 
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 Entresto.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the requested IGRT. You say that this is a necessary treatment technique. 
The Plan denied your request. The Plan says that the documentation does not show this type of regular imaging 
planning is necessary in this case. 
 
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 IGRT. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is an 87-year-old man with a diagnosis of locally advanced rectal cancer. The goal 
of treatment is palliative. A short course of radiation every other day has been advised. The enrollee's radiation 
oncologist cites the unique circumstances of the enrollee's urinary obstructive symptoms. The reason for the 
requested IGRT is to minimize urinary retention, as the enrollee has significant obstructive symptoms, and has 
required self-catheterization in the past. The radiation oncologist writes that there is no imaging technique that 
will allow for the proper alignment outside of IGRT, as bony landmarks will not be sufficient to achieve the 
clinical goal. The IGRT is determined to be medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested IGRT have been met. Therefore, we decided that the Plan has to 
pre-approve image-guided radiation therapy (IGRT).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy and retrograde filling for tooth #7 
coded as D3410 and D3430. 
 
You asked the Plan to pre-approve the apicoectomy and retrograde filling. You say that you have an infection 
in your tooth root that is spreading and not responding to antibiotics. The Plan denied your request. The Plan 
says your dental benefit does not provide coverage for this type of tooth treatment. 
 
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 an 
apicoectomy and retrograde filling for tooth #7 coded as D3410 and D3430.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tandem T:Slim Insulin Pump with Control IQ 
technology. 
 
You asked the Plan to pre-approve a Tandem T:Slim Insulin Pump with Control IQ technology. You say that 
you are diabetic and need this item to survive. The Plan denied your request. The Plan says that your doctor 
refused to order this device for you. 
 
The Plan must follow Medicare rules. Medicare rules say that the external insulin infusion pump must be 
ordered and follow-up care rendered by a practitioner who manages multiple beneficiaries on continuous 
subcutaneous insulin infusion therapy and who works closely with a team including nurses, diabetic educators, 
and dieticians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy. 
 
We looked at the file and Medicare rules. The file indicates your physician has refused to order an external 
insulin infusion pump for you. Based on this information, we decided that Medicare rules for coverage of a 
Tandem T:Slim Insulin Pump with Control IQ technology have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Tandem T:Slim Insulin Pump with Control IQ technology.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled 
nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered 
date.  You do not have complex wound care or other ongoing SNF level care needs. Your functional level is 
near baseline does not require skilled therapy services with the specialized skill, knowledge and judgment of a 
qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a 
SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF. Medicare coverage criteria are 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 SNF services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility 
(SNF) services.