Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines would not support the necessity of this invasive procedures at this point in 
management. In summary, there is insufficient documentation to support the medical necessity of cardiac 
catheterization in this enrollee's 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested mileage amount exceeds the limit listed by 
the Plan's routine transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way routine transportation trips each year, not to exceed 50 miles of driving 
distance per one-way trip. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The file shows that you are 
requesting additional mileage for routine transportation that exceeds the Plan's benefit limit for this service. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says based on the medical records received, the 
enrollee's condition does not meet the Medicare guidelines for an IRF admission. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (20936, 20930, 22612, 22840, 63047, 
63048). 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested services have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study through CED for beneficiaries with LSS who are enrolled in an approved clinical 
study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of spinal surgery have not been met. Specifically, the case record does not support that the enrollee is 
enrolled in an approved clinical study at this time. Therefore, we decided that the Plan does not have to pre-
approve spinal surgery (20936, 20930, 22612, 22840, 63047, 63048).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT Peripheral Nerve Stimulator (PNS) device. 
 
You asked the Plan to pre-approve a SPRINT PNS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 SPRINT PNS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT PNS device is experimental for chronic pain. More research is needed. 
 
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 SPRINT PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT Peripheral Nerve Stimulator (PNS) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services from an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve these services. You say that you have been overseeing the enrollee's care. 
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 
dialysis services from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 2 power wheelchair (PWC) with power tilt and power 
elevating leg rests. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met. 
 
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 medically necessary. Our physician reviewer found the power mobility evaluation dated 
September 8, 2022 indicates that the enrollee requires assistance with bathing and is independent with dressing 
and feeding. She has no history of skin breakdown. She is noted to have functional use of her upper and lower 
extremities with four out of five motor strength. She has severe pitting edema. She is functionally non-
ambulatory and cannot use a cane or walker for mobility. She cannot functionally propel a manual wheelchair 
due to her atrial fibrillation and congestive heart failure and chronic obstructive pulmonary disease (COPD) 
and becomes short of breath with minimal exertion. She cannot use a power scooter given that her home is not 
accessible for the turning radius. She requires a power wheelchair for mobility and accomplishing her daily 
activities. She has severe lower extremity edema and therefore requires power articulating footrests. Given her 
weight and difficulty with performing weight shifts and incontinence, she is at risk for skin breakdown and 
requires power tilt for pressure relief. A specialty evaluation has been performed. The requested Group 2 PWC 
with power tilt and power elevating leg rests is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a Group 2 power wheelchair (PWC) with power tilt and power elevating leg rests.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH. 
 
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 appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your 
request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HBOT (CPT code(s): G0277 and 99183). 
 
You asked the Plan to pre-approve the HBOT. You say that your treatment is for the condition that is related to 
the radiation you receive. You state that you have over 24 broken teeth in your jaw, and it is preventing you 
from eating. You state that you have a severe infection, and the requested services will help. The Plan denied 
your request. The Plan says your request is not medically necessary because your records do not show you have 
a confirmed diagnosis of osteoradionecrosis and are undergoing treatment. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the HBOT. Our physician reviewer 
found the provider is recommending HBO treatments before and after dental extractions to "prevent" 
osteoradionecrosis. You do not have a diagnosis of osteoradionecrosis at the current time. The review has 
determined that the medical records provided do not meet the requirements listed in the NCD for Medicare 
coverage. 
 
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 HBOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the HBOT (CPT code(s): G0277 and 99183).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA), lower 
extremity, with contrast material(s), including non-contrast images, if performed, and image postprocessing 
(73706). 
 
You asked the Plan to pre-approve CTA of the lower extremities. You say that the enrollee needs a CTA. The 
Plan denied your request. The Plan says in this case, in the absence of signs or symptoms of peripheral vascular 
disease, advanced imaging with CT angiography is not reasonable and 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 CTA of the lower extremities. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the enrollee has had no 
pertinent symptoms. The enrollee's ankle-brachial index (ABI) study does not confirm the presence of 
significant arterial stenosis. As such, guidelines for CT angiography are not met. In summary, there is 
insufficient documentation to support the medical necessity for CT angiography of the lower extremities 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 CTA of the lower extremities have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomographic angiography (CTA), lower extremity, with contrast 
material(s), including non-contrast images, if performed, and image postprocessing (73706).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental when used as bone graft material in 
spine surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that this is needed until you can have surgery. The Plan 
denied your request. The Plan says the Plan requires a trial of Monovisc, Orthovisc, Synvisc, or Synvisc-One 
before it will approve Durolane. 
 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 reviewer says that you 
do not meet criteria for a step therapy exception for Durolane. Our physician reviewer found you have not tried 
and failed the Plan's referred drugs of Monovisc, Orthovisc, Synvisc, or Synvisc-One. The record does not 
show that these drugs would likely be less effective and/or have adverse effects for you. 
 
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 use of Durolane.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot go to a lower level 
of care and meets the LTACH requirements for admission. The Plan denied your request. The Plan says 
admission to the LTACH is denied as not meeting criteria and not medically necessary. 
 
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 appears to be improving and more stable and should only require short-
term additional acute care services that can safely be provided at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH would not be clinically advantageous at this time and completion of treatment at the current 
facility is 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Byetta. 
 
You asked the Plan to pre-approve Byetta. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Byetta.  
 
Benefits for Byetta 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto. 
 
You asked the Plan to pre-approve Pluvicto. You say that the enrollee is unable to taxane chemotherapy as per 
medical oncology, and has been seen for a second opinion for a clinical trial. You also say that the enrollee has 
been treated with Xtandi hormonal therapy, and Abiraterone. The Plan denied your request. The Plan says the 
documentation provided for the requested medication not been proven for patients who have not received a 
prior treatment with a specific type of chemotherapy (taxane-based chemotherapy). The Plan also says the 
records do not document why the enrollee was unable to receive this chemotherapy or if there were other 
medical conditions that would interfere with using the taxane-based chemotherapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Pluvicto. Our reviewer says that 
Pluvicto is not medically reasonable and necessary for the enrollee. Our physician reviewer found the basis for 
denial in this case is that the patient has not received taxane based chemotherapy, and neither the clinical 
records nor the appeal letter address this. Our reviewer also found that it would not be within accepted 
standards of care to offer Lu-177-labelled prostate-specific membrane antigen (PSMA) in patients who have 
not received or been considered for taxane based chemotherapy 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pluvicto have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pluvicto.