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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you are appealing for the wrongful 
denial for intraosseous ablation of the basivertebral nerve, which is accomplished with the Intracept procedure. 
The Plan denied your request. The Plan says this procedure is considered experimental and investigational as 
medical studies have not proven that the service is helpful for the treatment of the enrollee's health problem. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says the services can be rendered by an in-network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM). 
 
You asked the Plan to preapprove the CGM. You say that the item should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the item denied correctly as the enrollee does not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services to be provided by the requested provider. You say 
that the patient requested a follow-up visit with this urologist. The Plan denied your request. The Plan says the 
service can be safely performed in a community care center. 
 
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 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on October 17, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were given a prescription medication 
while you were sedated and believe it is unfair for you to owe anything. The Plan denied your request. The 
Plan says self-administered drugs are not covered by 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 pay for self-administered drugs provided 
on October 17, 2022.  
 Benefits for self-administered drugs 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) 
procedure. 
 
You asked the Plan to pre-approve a MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the requested MILD procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MILD procedure. Our reviewer says 
that the requested MILD procedure is not medically necessary. Our physician reviewer found the MILD 
procedure is experimental. More research is needed 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 a MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pacemaker evaluation and adjustment provided on 
September 26, 2022. 
 
You asked the Plan to pay for pacemaker evaluation and adjustment. You say that the reconsideration for the 
requested referral or authorization was not received in the allotted time frame. The Plan denied your request. 
The Plan says Original Medicare is responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for pacemaker evaluation and adjustment provided on September 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that the requested proton 
beam radiation therapy (PBRT) is medically necessary. The Plan denied your request. The Plan says the 
requested proton beam radiation therapy (PBRT) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy (PBRT). 
Our reviewer says that the requested proton beam radiation therapy (PBRT) is not medically necessary. Our 
physician reviewer found proton therapy for prostate cancer is not experimental, and in fact is an accepted 
treatment approach.  While I do not think that proton therapy is an experimental therapy, any potential benefit 
or detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational 
question (being pursued in randomized studies- i.e. for intermediate to low risk prostate cancer). Other 
treatment approaches (IMRT +/- IGRT) are also highly effective and well tolerated. Thus, whether proton 
therapy affords a benefit over other standard approaches (IMRT/IGRT) for prostate cancer is an area of 
investigation and remains controversial.  To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is 
to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The enrollee was 
offered a registry study. Most of these registries enroll any patient receiving proton therapy for any disease 
(which in my opinion should not be sufficient for claiming medical necessity, as any and all patients treated 
with radiation therapy could then be considered for proton therapy without consideration for true need of this 
service). No specifics were given for this case. Notably, registry studies are not clinical trials or studies, and 
have a much less rigorous development process. A tumor registry does not address a specific scientific question 
but rather registers the patients clinical and treatment information into a database for potential analysis in the 
future. Nevertheless, it is not specified if a clinical trial review was sought or whether this insurer allows for 
clinical trial exceptions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency wheelchair van transportation 
services. 
 
You asked the Plan to pre-approve the non-transportation emergency transportation services. You say that the 
medical records provided support the need for the requested transportation services. The Plan denied your 
request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve the non-emergency wheelchair van transportation services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that the requested ILR is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for an 
implantable loop recorder (ILR). 
 
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 an implantable loop recorder (ILR). 
Our reviewer says that the enrollee does not meet criteria for an implantable loop recorder (ILR). Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lyrica capsules. 
 
You asked the Plan to pre-approve Lyrica capsules. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Lyrica capsules are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Lyrica capsules.  
 
Benefits for Lyrica capsules 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 an extraction, erupted tooth or exposed root (D7140 x5), 
and periodontal scaling and root planing - four or more teeth per quadrant (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits. 
 
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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider.  
 Therefore, we decided that the Plan does not have to pre-approve an extraction, erupted tooth or exposed root 
(D7140 x5), and periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly XT. 
 
You asked the Plan to pre-approve PuraPly XT. You say that the requested PuraPly XT is medically necessary. 
The Plan denied your request. The Plan says the requested PuraPly XT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PuraPly XT. Our reviewer says that the 
requested PuraPly XT is not medically necessary. Our physician reviewer found this diabetic enrollee 
developed an ulceration on October 12, 2022, measuring 6 cm x 2 cm x 5 mm. On January 10, 2023, the 
ulceration had reduced in size dramatically to 3 cm x 4 mm x 4 mm. This reduction was most likely attributed 
to routine debridement of the ulceration, offloading, and resolution of cellulitis with oral antibiotics. PuraPly 
XT is a collagen-based wound covering Food and Drug Administration (FDA) approved for ulcerations. Prior 
to application of the PuraPly XT, the plantar left foot ulceration was noted to be resolving nicely with dramatic 
improvement and reduction in size. It does not appear that the applications of PuraPly XT are absolutely 
necessary according to Medicare guidelines, as the enrollees ulceration was resolving nicely with routine 
debridement, offloading, and oral antibiotics. Therefore, the applications of PuraPly XT for this enrollees ulceration is not medically reasonable or 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 PuraPly XT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PuraPly XT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve intensity modulated radiation therapy (IMRT). You say that the requested 
IMRT is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for intensity modulated radiation therapy (IMRT). 
 
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 intensity modulated radiation therapy 
(IMRT). Our reviewer says that the enrollee does not meet criteria for intensity modulated radiation therapy 
(IMRT). Our physician reviewer found IMRT is a tool that clinicians can use when there is concern about 
sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms, i.e. the 
physician determines radiation treatment parameters to maximize dose to the target and minimize dose to 
normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the 
beam spatially and/or temporally. This enrollee is being offered palliative radiation to the pelvis to a low dose 
of 3 Gy x 10. IMRT for palliation of metastases is uncommon. For this case, there is no dosimetric rationale for 
IMRT or explanation for why IMRT would be needed over 2D or 3D radiation. IMRT can be considered 
medically necessary (even for palliation and/or non-standard indications) when justified by quantitative dose 
measures- when the dose-volume exposure of critical structures is unacceptable without IMRT. For this case, 
the volume is somewhat more complex than a case such that 3D radiation is plausibly needed over 2D 
radiation. However, the need for IMRT is not justified based upon quantifiable dosimetric measures or a 
plausible rationale. The American Society for Therapeutic Radiology and Oncology (ASTRO) model policy 
emphasizes the need to support IMRT with dosimetry; this would be of particular importance for clinical 
scenarios for which IMRT is not considered standard. In this case, IMRT would not be furnished in accordance with 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 intensity modulated radiation therapy (IMRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that the 
enrollee does not meet criteria for SNF admission. Our physician reviewer found the enrollee is with dementia 
with behaviors. From a nursing perspective, the enrollee received oral medications. The enrollee had stable 
vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and 
occupational therapy. The enrollee was at maximal assist level with functional mobility and non-ambulatory. 
The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.