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

 
We decided that the Plan does not have to pre-approve platelet rich plasma (PRP) injection (0232T). 
 
You asked the Plan to pre-approve PRP injection. You say that you are trying to avoid shoulder replacement 
surgery. You say that you would like to discuss all treatment options with your doctor. You also say that you 
feel not having this treatment option open to you would be detrimental to your health. The Plan denied your 
request. The Plan says the requested service 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 PRP injection. Our reviewer says that 
the requested PRP injection is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested PRP injections are considered experimental. The reviewer found that additional 
research is needed. Therefore, the reviewer found that the requested PRP injections are 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 PRP injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma (PRP) injection (0232T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis (81162). 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 gene analysis. You say that this testing is 
recommended. The Plan denied your request. The Plan says this testing is not covered because there is no 
documentation of any signs or symptoms of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA1 and BRCA2 gene analysis, is being requested solely for screening purposes. A test is considered screening when it is provided in the absence of signs/symptoms of illness or 
injury. In this case, the genetic test at issue is used to determine the presence of inherited cancer-causing 
mutations. However, the records do not show that you have any signs or symptoms suggestive of cancer. The 
documentation supports that this testing is requested due to a family history alone of ovarian and prostate 
cancer. This would be considered screening testing which is excluded from Medicare coverage. Therefore, we 
decided that the Plan does not have to pre-approve BRCA1 and BRCA2 gene analysis (81162).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also 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 Eliquis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 enrollee does not have complex nursing or rehabilitation needs. Medically 
necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee arthroscopy with meniscectomy (29883) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the requested service. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 
the knee arthroscopy with meniscectomy (29883) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and are able to be 
furnished safely and effectively only on an inpatient basis. 
 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 
You asked the Plan to pre-approve Euflexxa injections. You say that you have arthritis in your left shoulder, 
and your doctor wishes to use Euflexxa to lubricate your shoulder movements. The Plan denied your request. 
The Plan says the requested use of this drug for injection in a joint other than the knee is not a medically 
accepted use. 
 
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 Euflexxa injections. Our reviewer says 
that Euflexxa injections are not reasonable and necessary. Our physician reviewer found Euflexxa is not FDA-
approved for the treatment of impingement syndrome and osteoarthritis of the shoulder. Our reviewer found 
that although there is off-label support for use of Euflexxa for shoulder arthritis, the provided records in this 
case do not provide any imaging studies (or reports of imaging studies) of the left shoulder to confirm the 
presence of arthritis. Our physician reviewer also found without objective documentation of the diagnosis of 
arthritis with imaging, the use of the Euflexxa does not meet Medicare criteria for safe and effective and 
otherwise 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Euflexxa injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that you need this injection because you are in 
excruciating pain. You also say that you have tried other medications and they did not work. The Plan denied 
your request. The Plan says there is no documentation of an inadequate response, contraindication, or 
intolerance to the preferred product, Euflexxa. 
 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 Monovisc. Our reviewer says that you 
do not meet the coverage criteria for Monovisc. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that the Plan's 
required drug would likely be less effective and/or likely have adverse effects 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esomeprazole magnesium (Nexium). 
 
You asked the Plan to pre-approve Nexium. You say that the enrollee has tried and failed multiple medications. 
You also say that they are stable on Nexium. The Plan denied your request. The Plan says the requested drug is 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also 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 esomeprazole magnesium 
(Nexium).  
 Benefits for Nexium 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 Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Procrit or Retacrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed one of the preferred drugs. The reviewer found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultraviolet blood irradiation therapy to be provided by a 
chiropractor. 
 
You asked the Plan to pre-approve ultraviolet blood irradiation therapy. You say that this is a healthier 
alternative treatment for you. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve ultraviolet blood irradiation therapy to be provided by a chiropractor.
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 need inpatient admission to help you learn how 
to walk again as you have no physical help at home. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for sepsis, osteomyelitis and a below the knee amputation. Medical problems are stable. There are no 
complex or nursing rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. Medically necessary care can be provided 
in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that the requested MyoPro 
Motion G Orthotic device is medically necessary. The Plan denied your request. The Plan says the requested 
MyoPro Motion G Orthotic device 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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested MyoPro Motion G Orthotic device is not medically necessary. Our 
physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous sacroplasty. 
 
You asked the Plan to pre-approve percutaneous sacroplasty. You say that the success rate for this procedure is 
very high and recommended by your doctor. This procedure can help with mobility, hip pain, and strengthen 
daily activity. The Plan denied your request. The Plan says percutaneous sacroplasty is considered to be 
unproven and medically unnecessary 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 percutaneous sacroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this technique does not have sufficient evidence of efficacy and is considered 
experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous sacroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous sacroplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 5, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like this claim to be reprocessed 
towards payment. The Plan denied your request. The Plan says the rendering and referring providers are non-
participating providers with the Plan. The Plan also says that no services were authorized by the Plan. 
 
 
 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 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 the electrocardiogram (93010) provided on July 5, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial medial meniscectomy and/or repair. 
 
You asked the Plan to pre-approve partial medial meniscectomy and/or repair. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 partial medial meniscectomy and/or 
repair. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was being treated for a meniscus tear. 
Detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures. The exam did not demonstrate any mechanical symptoms, such as locking 
and/or giving way of the left knee. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial medial meniscectomy and/or repair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve partial medial meniscectomy and/or repair.