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

We decided that the Plan does not have to pre-approve epoetin beta (Mircera) to be provided at a dialysis 
facility. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
medication is not covered under Part B as an individually billed services when provided at the dialysis facility 
for the diagnosis of end stage renal disease. 
 
The Plan must follow Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment 
of ESRD are included in the ESRD PPS and are not separately paid. 
 
In this case, the CPT Code Manual definition of code J0887 is injection, epoetin beta, 1 microgram, (for esrd 
on dialysis). We find that CPT code J0887 is not separately payable. Therefore, we decided that the Plan does 
not have to pre-approve epoetin beta (Mircera) to be provided at a dialysis facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Rheumatologist visits (99215) to be provided by an 
out of network provider. 
 
You asked the Plan to pre-approve the out-of-network visits. You say that the out-of-network provider can 
better meet your needs. The Plan denied your request. The Plan says they have approved two visits with the 
out-of-network provider, but additional visits are not necessary, there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
Rheumatologist visits (99215) to be provided by an out of network provider.
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 the enrollee is confined to a chair. The appellant says 
that the enrollee requires rehab to get functional help through therapy. The Plan denied your request. The Plan 
says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely 
receive the services needed in another setting. 
 
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 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 is 
living at home after receiving care for a fracture of the left arm. The enrollee's medical conditions are stable. 
There are no medical needs requiring inpatient admission. 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 documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the volume of medication with each preferred drug 
would adversely affect treatment. The Plan denied your request. The Plan says you have not tried Visco-3, Gel-
one, Orthovisc, Synvisc, or Synvisc One. 
 
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 Durolane. Our physician reviewer 
found that you have unilateral primary osteoarthritis of the right knee. You have failed to adequately respond to 
aspiration. You have also tried a 3-injection series of Euflexxa. The Plan requires a trial of Visco-3, Gel-one, 
Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. You have not tried and failed 
the required drugs. There is no documentation provided indicating that the Plan?s required drugs are likely to 
be less effective, or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA of coronary arteries and CT coronary calcification. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found you have increased 
coronary risk but no evidence of coronary disease. In this circumstance, guidelines for the management of 
cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are 
endorsed by several national organizations. These guidelines currently do not recommend routine performance 
of specialized tests in the context of assessing coronary risk including coronary CT scanning and calcium 
scoring. Treatment change or addition based on the results of screening with coronary CT scanning has not 
been shown to improve cardiac outcome incremental to that achievable by treatment based on a combination of 
standard risk factor profiling and basic lipid analysis. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CTA of coronary arteries and CT coronary calcification.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (D4921). 
 
You asked the Plan to pre-approve gingival irrigation - per quadrant (D4921). You say that the enrollee needs 
these dental services. The Plan denied your request. The Plan says gingival irrigation is not a covered service. 
 
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 service is not covered by Medicare 
or the Plan. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation - per quadrant 
(D4921).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this service is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show no trial of the basic device with measurements for both legs before and 
after treatments. 
 
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 device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that this patient has lymphedema of the chest, trunk, or abdomen on 
an objective physical examination. The enrollee does not have unique characteristics on a physical exam that 
would indicate the segmented pump over a standard pump. There is no documentation of a four-week trial and 
failure of the standard pump with measurements of both legs before and after treatments. The criteria for an 
E0652 pump have not been met per Local Coverage Determination (LCD): Pneumatic Compression Devices 
(L33829). 
 
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 a segmented pneumatic compression device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction for the enrollee. 
 
You asked the Plan to pre-approve the extraction. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 a 
dental extraction for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and 
suspension sleeve (L2397) provided August 7, 2020. 
 
You asked the Plan to pay for the orthoses. You say that please see the attached documents which prove 
medical necessity of the equipment you provided. The medical records contain packing slip too. Please review 
and process the claim for payment. The Plan denied your request. The Plan says the billed service cannot be 
verified as the documentation submitted did not indicate the provider discussed the need for the billed supply 
code. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is reported to have chronic, bilateral knee pain.  No recent knee injury or surgery is 
reported.  No review of systems or physical examination, including weakness and/or deformity, of the knee is 
documented.  There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy 
provision/response (i.e. prescription meds, injections, PT/OT) having been provided.  There is no 
documentation related to back pain.  Therefore, the documentation does not support the medical necessity or 
reasonableness of the provided 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 the orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided 
August 7, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda 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 that the enrollee does not meet the indications, criteria, and guidelines for the use of 
Keytruda. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable or necessary. Our physician reviewer found this review relates to a 
request for Keytruda to be given with Carboplatin and ALIMTA to treat a 72 year old man with metastatic 
adenocarcinoma of lung who had 1 cycle of these drugs in 2018 before it was learned he had an EGFR exon 19 
deletion and was switched to TAGRISSO.  He now has progression of the cancer on TAGRISSO (osimertinib). 
The original 1 cycle of chemotherapy did not have adequate use to determine activity of the drugs. Therefore, 
the use at this time would be considered second line or subsequent therapy to the TAGRISSO. The enrollee has 
adenocarcinoma, a type of non-small cell lung cancer that is metastatic. He has progressed on anti-EGFR 
treatment. Keytruda will be given with Carboplatin and ALIMTA. Per the FDA website there are no 
contraindications to the use of Keytruda. The submitted documentation supports that the requested use of 
Keytruda in combination is medically reasonable and necessary and that it is safe and effective for 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that picture studies are not supported to guide this type of treatment. 
 
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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found SBRT, delivering high fractional doses in 4-5 fractions is an established approach for the treatment of 
discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate 
system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. Data 
suggest that SBRT would be superior to conventional palliative radiotherapy. The appeal letter addresses the 
need for SBRT in this enrollee. SBRT is within the accepted standards of care (as elucidated by the ASTRO 
model policy). It would meet the general medical necessity criteria by virtue of treatment furnished according 
to accepted standards of medical practice. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy 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 Nucynta. 
 
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 Nucynta.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the Zostavax vaccine you received on August 12, 2020. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not 
covered under Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine you received on August 12, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D1999, D0364) 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 (D1999, D0364)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that you have extreme pain every day. 
The Plan denied your request. The Plan says the records do not show you have had a trial of standard treatment 
methods. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Your medical records do not show you have tried physical therapy, 
NSAIDs or other treatment. Based on this information, we decided that Medicare rules for coverage of 
sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a pneumatic compression device (E0652). 
 
You asked the Plan to provide a pneumatic compression device. You say that the enrollee's medical team 
determined the enrollee would not receive safe or satisfactory treatment with a basic device. The Plan denied 
your request. The Plan says the enrollee has not had a four week trial with a basic pneumatic compression 
device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device 
(E0652).