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

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested service. You say that the additional use of the Coflex device 
will provide lasting stability to the posterior spine. The Plan denied your request. The Plan says there is no 
evidence of improved outcomes using the requested implanted device. 
 
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 service. Our physician 
reviewer found that the requested device remains experimental for the treatment of spinal disorders. More 
research is needed to show safety and efficacy. Therefore, the requested service is not medically reasonable or 
necessary to treat the enrollee. 
 
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 service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology services. You say that you would like approval to see this 
doctor. The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services 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 a gradient compression wrap (A6545) 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit, except as a wound dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a gradient 
compression wrap (A6545)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis with and without contrast.

You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CT scans. Our reviewer says that the documentation does support that the requested CT scans are medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosed indeterminate renal lesion found on ultrasound measuring 2.7  x 1.5 cm. Based on the ultrasound report provided showing an incidental mass on the left kidney, it is reasonable and medically necessary to undergo CT with and without contrast to further evaluate the lesion. Therefore, the enrollee meets criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis with and without contrast. 

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 Daliresp for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B progarms can only provide limited benefits for prescription drugs. 
 
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 Daliresp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. 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. 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 Zilretta. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found review of compendia note that safety and 
efficacy of repeat administration of Zilretta have not been demonstrated. As repeat injections are not 
recommended by the FDA, medical necessity for a second injection cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dehumidifier. 
 
You asked the Plan to pre-approve dehumidifier. You say that this dehumidifier is necessary for you. The Plan 
denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a dehumidifier is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of dehumidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a dehumidifier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 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 medically necessary. Our physician reviewer found the enrollee was admitted for a 
cerebrovascular accident. His medical problems are now stable and he has no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. He does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your request does not meet criteria for coverage of this 
dental benefit. 
 
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.  
 
We looked at the case file and Plan?s rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, a full mouth debridement is not allowed for one 
calendar year following a prophylaxis (D1110). The record shows that a prophylaxis was provided to the 
enrollee on September 14, 2020, less than one calendar from your request. Therefore, we decided that the Plan 
does not have to pre-approve a full mouth debridement (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve a PMD. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you are able to operate a manual wheelchair or other assistive device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power mobility device (PMD).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient admission.
You asked the Plan to pre-approve inpatient admission. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
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 inpatient admission. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a harm to themselves and there is no safe place at this time for disposition. It would be a different case if the enrollee/family were refusing placement. There is no place, at the time of these records, to safely discharge this enrollee. 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 have been met. Therefore, we decided that the Plan has to pre-approve inpatient admission.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump 
(E2402) and wound care set (A6550) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a negative pressure wound therapy electrical pump and wound care set. You 
say that the items are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these items. Therefore, coverage criteria has not been met. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a negative pressure wound therapy electrical pump (E2402) and wound care set (A6550) to be provided by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs a greater occipital 
nerve block for migraine control. The Plan denied your request. The Plan says the injection is considered 
experimental for the treatment of occipital neuralgia because the effectiveness for this indication 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 the requested services. Our physician 
reviewer found that the enrollee has a diagnosis of chronic migraine without aura, intractable, with status 
migrainosus. There is insufficient evidence that greater occipital nerve blocks are safe and effective for the 
management of migraine headaches. Therefore, the requested service is not medically reasonable or necessary 
to treat the enrollee. 
 
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 an occipital nerve injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the Group 2 heavy duty power 
wheelchair (PWC) purchased on April 18, 2020. 
 
You asked the Plan to provide reimbursement for the Group 2 PWC. You say that you are very limited in what 
you can do without a PWC. You were told that this would be covered if you sent in the bill. You feel that this is 
medically necessary as it allows you to have a more normal life. The Plan denied your request. The Plan says 
there is insufficient documentation of medical necessity. This PWC was purchased without an order from your 
treating physician and without evaluation by a physical therapist. The medical records from after this purchase 
still do not show that Medicare coverage criteria are met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 provide reimbursement for the Group 2 PWC. Our 
reviewer says that the documentation does not support the medical necessity of the purchased PWC. Our 
physician reviewer found the documentation does reveal that the patient has a personal mobility deficit that 
impairs participation in MRADLs in the home per a 10/5/20 progress note. The documentation does not reveal 
why the patient's mobility deficit is unable to be helped by a manual wheelchair. There is no objective detailed 
neuromuscular exam or the upper extremities indicating inability to use a manual wheelchair. The 
documentation is not clear that the patient can safely  maneuver the power mobility scooter in the home or that 
the requested power operated scooter will significantly improve1 MRADL performance in the home. 
 
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 Group 2 PWC have not been met. Therefore, we decided that the Plan does 
not have to provide reimbursement for the Group 2 heavy duty power wheelchair (PWC) purchased on April 
18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dental Services (D4921, D4910, D0180). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these dental services are not a covered benefit. 
 
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 
Dental Services (D4921, D4910, D0180).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures to be provided by an out of network dental 
provider. 
 
You asked the Plan to pre-approve the dental items. You say that you are not satisfied with the dentures that 
you received. You say that the dentist would not let you get the dentures that you wanted. You also say that you 
would like to go to an out of network dental provider for new dentures. The Plan denied your request. The Plan 
says dental items must be provided in network in order to be applied to your benefit. The Plan also says that 
you have used up your denture benefit for this year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental items are only covered when 
you receive them from a participating dental provider. Additionally, the denture benefit for 2020 has been used 
up. Therefore, we decided that the Plan does not have to pre-approve dentures to be provided by an out of 
network dental provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure Plus. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says nutritional supplements are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ensure Plus.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says there is no 
documented history of viscosupplementation therapy. The Plan also says that there is no history of failure, 
contraindication, or intolerance to the formulary alternatives: Synvisc, Durolane, and Gelsyn-3, and this is not a 
continuation of therapy in the past 365 days. 
 
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 Gel-one. Our reviewer says that Gel-
one is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no 
documentation of a first line visco drug use such as Synvisc. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Keytruda is FDA-approved as single-
agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression (TPS greater than or 
equal to one percent), as determined by an approved test, and with disease progression on or following 
platinum-containing chemotherapy. It is not supported by major drug compendia or the medical literature for 
patients with PD-L1 expression of less than one percent; therefore, the Keytruda is not reasonable or medically 
necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.