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

We decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation (76376, 76377, 76380), and CT, upper extremity; without contrast material (73200, 73201 and 73202), for the enrollee.
You asked the Plan to pre-approve the imaging. 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. 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 the imaging. Our physician reviewer found the review has determined that there is no NCD or LCD for this request. A review of the documentation shows that the CPT code M24.00 is loose body in non-specific joint. The request for several CT for both forearm is 3D reconstruction of both wrists. The procedure is new and the article provided says "to our knowledge, no study has yet been performed comparing 3D planning with other planning methods for treatment of distal radius malunions, so the added benefit of this technique is not yet clear. The review has determined that the requested bilateral 3D scans of the member's wrist are 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation (76376, 76377, 76380), and CT, upper extremity; without contrast material (73200, 73201 and 73202), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care for the enrollee. 
 
You asked the Plan to pre-approve inpatient mental health care for the enrollee. You say that inpatient 
admission is 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 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 inpatient 
mental health care. Our reviewer says that Medicare criteria for inpatient mental health are not met. Our 
physician reviewer found based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal 
ideation noted and denied any auditory or visual hallucinations. The enrollee is cooperative/calm with 
treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as she did not have dangerousness to self or others but was compliant with her treatment. 
There is no individualized treatment plan submitted. The enrollee does not meet the criteria for continued acute 
inpatient mental health treatment for the dates in question of August 21, 2020 forward as this enrollee was not 
shown to be a danger to herself or others. 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 
inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-
approve inpatient mental health care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this device is 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. 
Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found coverage criteria 
for a home ventilator are not met.  This enrollee has severe COPD with chronic hypoxic and hypercapnic 
respiratory failure. The enrollee has not tried and failed BiPAP at home, according to Medicare criteria.  
Medicare does not cover a ventilator when used as BiPAP.  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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coolief RFA. 
 
You asked the Plan to pre-approve Coolief RFA. You say that the requested Coolief RFA is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for Coolief RFA. 
 
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 Coolief RFA. Our reviewer says that 
the enrollee does not meet criteria for Coolief RFA. Our physician reviewer found the enrollee presents with a 
history of left knee pain and stiffness, and onset of right knee pain, stiffness and crepitus in early 2020. Clinical 
exam findings have documented symmetrical range of motion, right knee crepitus, functional range of motion, 
no tenderness to palpation, and 4/5 to 5/5 strength. X-rays have reportedly shown patellofemoral 
chondromalacia and arthritic changes, left greater than right. He has reportedly failed long-term conservative 
treatment, including activity modification, medications, bracing, physical therapy, cortisone injections, and 
viscosupplementation injection. He underwent bilateral knee genicular nerve blocks with reported benefit. 
Under consideration is a request for Coolief RFA for the bilateral knees. Medicare coverage criteria have not 
been met. Guidelines do not support non-thermal RF modalities. The enrollee does not have a covered 
indication relative to the L35936 Local Coverage Determination which addresses spinal facet joint treatment. 
Additionally, there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
these procedures for this enrollee as discussed above. Therefore, this request for Coolief RFA is not medically 
reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Coolief RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Coolief RFA.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 9-month supply for a continuous glucose monitor 
and related supplies for the enrollee. 
 
You asked the Plan to pre-approve 12 months of supplies for the enrollee. We note the Plan approved a 3-
month supply. You say that these supplies are medically necessary. The Plan denied your request. The Plan 
says that while a 3-month supply was approved, the additional 9 months were denied. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of equipment.  
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 9 months of supplies. Our reviewer says 
that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee meets the required criteria. He is followed by his MD every 3-6 months as his provider 
deems reasonable and per Medicare policy. This is not initial use. There was an adjustment made in his ?nph? 
dose on April 14, 2020 and he was seen again on July 14, 2020. The actual supplies can be sent out in 3-month 
quantities, but he clearly meets criteria for ongoing Dexcom G6 use. We looked at this physician's review, the 
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 months of 
supplies. Therefore, we decided that the Plan has to pre-approve a 9 month supply for a contiguous glucose 
monitor and related supplies for the enrollee in addition to the 3 months already approved by the Plan.  
 
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 magnetic resonance imaging (MRI) of the brain for then enrollee. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that an MRI is medically necessary. The Plan 
denied your request. The Plan says that Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered 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 an MRI of the brain. Our 
reviewer says that Medicare coverage criteria are met. Our physician reviewer found the enrollee is a 72-year-
old female diagnosed with metastatic lung cancer to the brain and is status post gamma knife procedure. In this 
case an MRI of the brain to assess response to gamma knife therapy is medically reasonable and necessary. 
Medicare coverage criteria are 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 an MRI of the brain have been met. Therefore, 
we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for then 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment (D6056), and abutment supported porcelain fused to metal crown (D6061). 
 
You asked the Plan to pre-approve the endosteal implant, prefabricated abutment, and abutment supported 
porcelain fused to metal crown. You say that these services are medically necessary. The Plan denied your 
request. The Plan says these services are not covered benefits. 
 
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 
surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment 
supported porcelain fused to metal crown (D6061).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 function level prosthesis and related components. 
 
You asked the Plan to pre-approve the requested prosthesis and related components. You say that this 
prosthesis is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 
not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this item. 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 prosthesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the items in appeal( L5920,L5631,L5987,L5986,L5840,L5845,L5850) are not medically 
necessary per the  Section 1862(a) (1) (A) of the Social Security Act and the Local Coverage Determination 
(LCD): Lower Limb Prostheses (L33787).  The requested The L5920 is not medically necessary as this non 
align able system is not able to be used with the approved preparatory socket therefore this request is not 
considered safe and effective for your medical condition. The request for an L5631-Addition to lower 
extremity, above knee or knee disarticulation, acrylic socket exceeds the patient's medical need as the 
preparatory initial prosthetic leg does not require acrylic material. The L5987-All lower extremity prosthesis, 
shank foot system with vertical loading pylon,L5986-All lower extremity prostheses, multi-axial rotation unit 
('mcp' or equal),L5840-Addition, endoskeleton knee/shin system, 4-bar linkage or multiaxial, pneumatic swing 
phase control,L5845-Addition, endoskeleton, knee-shin system, stance flexion feature, adjustable, and L5850-
Addition, endoskeleton system, above knee or hip disarticulation, knee extension assist all exceeds your 
medical need and are not furnished in a setting appropriate to your medical needs and condition as the 
documentation does not reveal supporting physician or therapy progress notes indicating evidence that you are 
a K3 ambulator. 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 the requested prosthesis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a K3 function level prosthesis and related components.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coolief radiofrequency treatment services. 
 
You asked the Plan to pre-approve the requested services. You say that the injection is part of the whole spine. 
The Plan denied your request. The Plan says non-thermal radiofrequency modalities are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal modalities for facet joint 
denervation are considered not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on the information provided, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief 
radiofrequency treatment services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve bortezomib injections. 
 
You asked the Plan to pre-approve the bortezomib injections. You say that this is a supported treatment. The 
Plan denied your request. The Plan says that there is no evidence that this drug can be used in this 
circumstance. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bortezomib injections. Our reviewer 
says that the requested use of this drug is considered reasonable and necessary. Our physician reviewer found 
the enrollee has refractory antibody-mediated liver rejection for the third time since June. The use of this drug 
to treat organ rejection is supported in the Medicare approved compendia, including articles in the American 
Journal of Transplantation from 2012, Transplantation direct, in 2019, and American Journal of 
Gastroenterology in 2018. 
 
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 bortezomib injections have been met. Therefore, we decided that the Plan 
has to pre-approve bortezomib injections.  
 
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 Febuxostat. 
 
You asked the Plan to pre-approve Febuxostat. The Plan denied your request. The Plan says the drug is not 
covered for the enrollee's condition by the Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Febuxostat.  
 
Benefits for Febuxostat 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an N95 mask.
You asked the Plan to pre-approve the mask. You say that you need to protect yourself against COVID-19. The
Plan denied your request. The Plan says Medicare does not cover non-reusable disposable items.
The Plan must follow Medicare rules. Medicare rules say that non-reusable disposable items are not covered.
The requested mask would be non-reusable and disposable. Based on this information, we decided that
Medicare rules for coverage of the mask have not been met. Therefore, we decided that the Plan does not have
to pre-approve an N95 mask.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this transfer is 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the records provided, the enrollee does not require any services in the 
proposed LTACH that are not already available in the current setting. Therefore, this request for LTACH 
services will be considered not medically necessary at this time. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute 
care hospital (LTACH) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 there are no identifiable skilled nursing service needs. The enrollee does not require skilled 
nursing or skilled therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 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 for the enrollee.