Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553). 
 
You asked the Plan to pre-approve CGM and supplies. You say that the enrollee needs this device to regulate 
her blood sugar throughout the day and night. The enrollee's blood sugar is getting low at night, and she has to 
get up in the middle of the night to check it. The Plan denied your request. The Plan says the enrollee does not 
meet coverage criteria for approval of 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or 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 CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous ablation of the basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that this procedure improves the quality of 
life of patients suffering from vertebrogenic low back pain. The Intracept Procedure, not just the device 
received initial FDA clearance the summer of 2016. That clearance means the procedure is safe and effective. 
The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the Intracept procedure targets the basivertebral nerve for 
the relief of chronic vertebrogenic low back pain. Medicare guidelines consider this type of system unproven 
and not medically necessary. Large well-designed studies in the peer review scientific literature comparing 
stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not 
demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard 
surgical treatment. In this case, the review has determined that the requested Intracept procedure is not 
medically reasonable or necessary 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 an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intraosseous ablation of the basivertebral nerve (64628, 64629).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve nasal valve repair with the Latera absorbable implant for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies have not proven that this device is helpful for treatment of the 
health problem. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that evidence in the medical literature supports that the Latera absorbable implant is safe, and improves 
breathing in patients with nasal wall collapse at two-years of follow-up. The procedure would allow the 
enrollee to avoid more extensive rhinoplasty surgery. The documentation supports that the proposed implant is 
medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve nasal valve repair with the Latera absorbable implant 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for multiple services on April 21, 2022, to May 
4, 2022. 
 
You asked the Plan to waive the copayment for multiple services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 
$295.88 deductible for multiple services.  
 
 
 
 
 
 
 You have been asked to pay a $295.88 deductible for multiple services. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for multiple services on April 21, 2022, to May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that a home 
ventilator is not medically necessary. This patient has severe chronic obstructive pulmonary disease (COPD) 
and arterial blood gas (ABG) during a recent hospitalization was consistent with acute on chronic CO2 
retention. The patient may benefit from BiPAP with AVAPS during sleep as an outpatient. But Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 29, 2022, to May 
1, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that this hospitalization qualifies for inpatient payment under the two-midnight rule. The 
enrollee presented for a procedure on 4/28/2022. The procedure did not go as expected and the enrollee was 
kept overnight (4/28-29/2022).  On 4/29/2022, the enrollee had a decrease in his renal function and a plan was 
put in place to try the procedure by different means. The enrollee was expected to stay a second midnight 
(4/29-30/2022) and an order was written converting the patient to inpatient status. That the second procedure 
was later deferred, does not negate the treating physicians' intent or make the monitoring of the enrollees renal 
function unreasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 29, 2022, to May 1, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee was admitted with respiratory failure requiring mechanical ventilation. 
The record indicates that the enrollee is improving but still require acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be recommended. 
 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. 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. 
 
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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
the plan's required drugs would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Bevacizumab-awwb biosimilar, and 
Docetaxel. 
 
You asked the Plan to pre-approve Carboplatin, Bevacizumab-awwb biosimilar, and Docetaxel. 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 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 Carboplatin, Bevacizumab-awwb 
biosimilar, and Docetaxel. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the requested drugs are not FDA-approved for the enrollees diagnosis. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin, Bevacizumab-awwb biosimilar, and Docetaxel have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Bevacizumab-awwb biosimilar, 
and Docetaxel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee was admitted with myocardial infarction and required operative 
intervention. The record indicates that the enrollee developed acute hypoxic respiratory failure and still requires 
acute care services. The enrollee continues to receive acute care services and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested 
service cannot be recommended. 
 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve progressive lenses (V2781) and frames (V2020). 
 
  You asked the Plan to pre-approve progressive lenses (V2781) and frames (V2020). You say that it was not 
even two months from when you got your glasses and were watching television, that you heard a crack and 
realized that the left side frame of your glasses was cracked and fell off. You also say you need glasses to drive 
and will last at least a year without breaking. The Plan denied your request. The Plan says the benefit is 
exhausted. The Plan also says that they cover up to one pair of complete eyeglasses or disposable contact lenses 
every year, and the member purchased eyeglasses on August 10, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to one pair of complete eyeglasses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover up  to one pair of complete eyeglasses 
or contact lenses every year. The record shows you purchased eyeglasses on August 10, 2022. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781) and frames (V2020) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve progressive lenses 
(V2781) and frames (V2020).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist. 
 
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 the services are available from network providers. 
 
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 referral to an out-of-network physical therapist.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 enrollee was admitted for COPD exacerbation. Medical problems are stable. 
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 supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 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: 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 would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says IRF is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as skilled nursing facility 
(SNF), home health or outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the coverage criteria for this admission has not been met. The enrollee is 
medically stable and does not need physician close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not 
need 3 hours a day x 5 days a week of therapies with multidisciplinary approach in an IRF. The enrollee's rehab 
needs can be safely met in a lower intensity setting. The enrollee's rehab needs can be safely provided in an 
alternate and low intensity setting such as in a skilled nursing facility. 
 
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.