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

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
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 step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not support that the 
required drugs would be contraindicated or less effective; therefore, Monoferric is not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0637). 
 
You asked the Plan to pre-approve the orthosis. You say that this equipment is medically necessary. The Plan 
denied your request. The Plan says the documentation is insufficient to support the request. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. Without a standard written order from the physician, the 
request is not supported. Therefore, we decided that the Plan does not have to pre-approve a lumbar-sacral 
orthosis (L0637).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve therapy services. You say that the requested therapy is medically necessary. 
The Plan denied your request. The Plan says that the therapy services are not covered when received by an 
OON 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 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 
outpatient therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy. 
 
You asked the Plan to pre-approve electronic brachytherapy. 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that you have basal cell carcinoma of the nose. There 
is insufficient literature to support the use of the requested service for your specific clinical condition. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic brachytherapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu, Fosaprepitant, Ondansetron, and 
Dexamethasone. 
 
You asked the Plan to pre-approve Enhertu, Fosaprepitant, Ondansetron, and Dexamethasone. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drugs are not 
medically necessary. 
 
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 Enhertu, Fosaprepitant, Ondansetron, 
and Dexamethasone. Our reviewer says that the documentation does not support that the requested drugs are 
medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of HER2 
negative metastatic esophageal cancer. The Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. Since criteria for Enhertu is not met, the other medications are not needed. Therefore, the enrollee does not 
meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu, Fosaprepitant, Ondansetron, and Dexamethasone have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Enhertu, Fosaprepitant, Ondansetron, and 
Dexamethasone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept) procedure (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is considered experimental as additional research is needed. 
Therefore, the reviewer fond that the requested procedure is not 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept) procedure (64628, 
64629).
Appeal type: Drugs
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 this is medically necessary. The Plan denied your 
request. The Plan says the requirements for coverage have not been met. 
 
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. 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 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 based on the documentation provided, coverage criteria has 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 the enrollee had a normal cardiac catheterization in 2015 performed to evaluate the 
same symptoms, as well as a radionuclide stress test performed several months ago, and interpreted as low-risk. 
Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time cardiac 
catheterization would not be considered medically appropriate and necessary 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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Powered pressure reducing air mattress (E0277). 
 
You asked the Plan to pre-approve the Powered pressure reducing air mattress. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the criteria listed 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 the Powered pressure reducing air 
mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found the records 
do not document that the patient has multiple stage 2 pressure ulcers located on the trunk or pelvis which have 
failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer 
treatment program or that she has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or that 
she has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days. 
 
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 Powered pressure reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Powered pressure reducing air mattress (E0277).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an evaluation with a vein specialist. 
 
You asked the Plan to pre-approve the evaluation. You say that the enrollee complains of painful varicose veins 
on bilateral legs. You also say that they report chronic veins and progressively worsening pain. The Plan denied 
your request. The Plan says that the requested service is not medically necessary. 
 
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 evaluation. Our reviewer says that 
the requested consultation with a vein specialist is considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates the enrollee has painful varicose veins that 
are getting progressively worse and are made worse with prolonged standing. The reviewer found that there 
may be other important reasons for the enrollees leg symptoms that might be clarified by a vein specialist. 
Therefore, the reviewer found that the consultation with a vein specialist is medically reasonable and 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 the evaluation have been met. Therefore, we decided that the Plan has to pre-
approve an evaluation with a vein specialist.  
 
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 pre-approve Breo Ellipta Inh 200-25. 
 
You asked the Plan to pre-approve a prescription drug. You say that the enrollee has tried so many other 
different medications. She needs to stay on this med because this is the only med that has her breathing under 
control. The Plan denied your request. The Plan says the requested medication does not fall under Part B 
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 Breo Ellipta Inh 200-25.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that the requested drug has been effective in the 
enrollee's treatment. The Plan denied your request. The Plan says the requested drug is not covered under 
Medicare 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 pre-approve Mounjaro.  
 
Benefits for Mounjaro 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve power seat elevation feature (E2300). You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested power seat elevation system is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation feature is not a covered 
benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature (E2300) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve power seat elevation feature (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation procedure (64635, 
64636). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat facet joint radiofrequency ablation at the same 
anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 
consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living as compared to baseline 
measurement using the same scale. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that this procedure is not medically necessary. Our physician reviewer found the patient did 
not achieve the required level of pain relief from the previous procedure, therefore the request repeat procedure 
is not 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 the radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a repeat radiofrequency ablation procedure (64635, 64636).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the polycarbonate or equal lenses (V2784) purchased on August 11, 
2022. 
 
You asked the Plan to pay for the polycarbonate or equal lenses. You say that you were allowed a $200.00 
benefit, and spent $197.00 during your visit. You also say that you did not request the polycarbonate lenses. 
The Plan denied your request. The Plan says that this service is a non-covered benefit because your benefit was 
previously exhausted. 
 
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 $200 for one (1) pair of eyeglass lenses and frames or contacts every year. 
 
We looked at the file and the Plan's rules. Specifically, the record does not show that you met your $200 
eyewear allowance for the 2022 benefit year prior to this date of service. Based on this information, we decided 
that the Plan's rules for coverage of the polycarbonate or equal lenses have been met. Therefore, we decided 
that the Plan has to pay for the polycarbonate or equal lenses (V2784) purchased on August 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with routine laboratory testing and x-rays 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the. You say that the enrollee needs urgent surgery. You say that the 
enrollee needs to be cleared from a cardiac and pulmonary standpoint prior to surgery. You also say that the 
pre-operative testing needs to be done as soon as possible. The Plan denied your request. The Plan says there 
are in-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 confirmed there are 
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 an office visit with routine laboratory testing and x-rays to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary 
source documentation does not contain sufficient detailed information in the medical record to justify the 
treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with 
average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is available upon request. The elements of the coverage criteria 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.