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

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (CPT code 
22513). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is not able to walk because they have 
a compression fracture and when they walk, the enrollee is in a lot of pain. You state the compression back 
brace is not helping, and the spinal cord stimulator is not working anymore either. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records show their 
symptom onset began in February 2022. 
 
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 physician reviewer 
found the detailed documentation is not evident regarding an acute (less than 6 weeks) or subacute (6-12 
weeks) compression fracture. The enrollee notes the symptoms have been present since February 2022. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the medical records provided do not meet the requirements 
listed in the LCD 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (CPT code 22513).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 26, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the psychotherapy 
services were not medically necessary based on the Medicare LCD. 
 
The Plan follows Medicare rules. 
 
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 psychotherapy. Our reviewer says that the 
psychotherapy was not medically necessary. Our physician reviewer found that this enrollee is being treated for 
Major Depressed Disorder, Single Episode, Unspecified. The enrollee had been seen by the social worker 1 or 
2 times per week since September 2021. There is no documented individualized treatment plan showing the 
type, amount, frequency and duration of services as is required. The enrollee was documented as having 
confusion and disorientation yet there was no outline of capacity of how the enrollee would benefit from this 
therapy. The enrollee was given therapy with no expectation of improvement based on the mental status of the 
enrollee. Based on review the records provided, this enrollee does not meet the criteria for psychotherapy 
without a treatment plan or outline of benefit from therapy therefore does not meet the criteria utilizing LCD 
L33632.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not 
have to pay for psychotherapy provided on February 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740) and a pontic (D6245), provided by 
an out-of-network provider on March 16, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the denied services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown (D6740) and a pontic (D6245), provided by an out-of-network provider on March 16, 2022.
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. You say that the enrollee meets the Medicare criteria 
for LTACH admission, and the enrollee will benefit from it. The Plan denied your request. The Plan says the 
records do not show the enrollee meets LTACH admission criteria. The enrollee's continued care needs include 
skilled nursing and therapy as they recuperate from the hospital stay. When the enrollee is ready to leave the 
hospital, they can safely receive this care in another setting, such as a skilled nursing facility or at home with 
home health services. 
 
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 that the short-term acute care hospital can provide for all of the enrollee's present 
inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. The Plan 
has not stated that continued care in the short-term acute care hospital will not be covered. 
 The enrollee presently does not appear to be stable for transfer. The enrollee is receiving appropriate services in 
the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate until the 
enrollee is stable to transfer to either an LTACH in the future or to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or 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 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 oxycodone 20MG extended-release (ER) tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says oxycodone is a self-administered drug and 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 oxycodone 20MG 
extended-release (ER) tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the enrollee has been experiencing 
knee pain that is aggravated by movement, activity, stairs, and lying down. You state the enrollee has been 
experiencing constant numbness and muscle weakness. You state the enrollee was diagnosed with osteoarthritis 
of their right knee and they have tried over the counter medications, topical creams and has had four Visco 
injections. You state the enrollee is having difficulty walking and trouble with their activities of daily living 
and the most recent x-rays show bone on bone articulations over the medial compartment and severe medial 
joint space narrowing with Varus alignment. The Plan denied your request. The Plan says there must be a trial 
and failure of three months of physician directed conservative management that shows functional limiting pain 
at a short distance. The Plan states as well as, trial and failure of physical therapy. 
 
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 the total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. The documentation does not indicate 
a trial and failure of physical therapy. Additionally, the last Visco/steroid injection was on May 4, 2022, and exam dated July 27, 2022, did not indicate this failed to provide benefit. 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 requested right total knee arthroplasty (CPT 27447), in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one (J7325). 
 
You asked the Plan to pre-approve Synvisc-one. The Plan denied your request. The Plan says the records do 
not show that the enrollee has had a poor response to other drugs first. 
 
  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 Synvisc-one. Our reviewer says that 
Synvisc-one is not reasonable and necessary. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug(s). Our reviewer also found that there is no indication that the 
Plan's required drug(s) 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 Synvisc-one have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one (J7325).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for use in 
combination treatment with the already approved Enhertu. The Plan denied your request. The Plan says 
medical studies haven't proven that Keytruda in combination with Enhertu is helpful for treatment of the 
enrollee's health problem. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the use of pembrolizumab with fam-
trastuzumab deruxtecan-nxki is not FDA-approved for the treatment of Stage 4 breast cancer. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. The documentation does not support that the use of pembrolizumab with fam-trastuzumab deruxtecan-
nxki 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vitrectomy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the vitrectomy. You say that you had an appointment with this provider and 
have built trust with them. You say you would prefer to this doctor to perform your eye surgery. The Plan 
denied your request. The Plan says the provider is out-of-network. 
 
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 vitrectomy in this appeal. We found no exception that would require the Plan to 
pre-approve the vitrectomy. The records provided for review do not show that the vitrectomy is urgent or 
emergent. Therefore, we decided that the Plan does not have to pre-approve the vitrectomy 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 recliner with massage and heat functions (E1399). 
 
You asked the Plan to pre-approve the recliner. You say that the chair is medically necessary. The Plan denied 
your request. The Plan says the lift mechanism has already been approved. The chair and other features are not 
medical items and are non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner with massage and heat functions (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on January 13, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed".  
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug testing services (G0483) provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 13, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the services provided on December 13, 2021 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records show the enrollee does not have imaging studies available 
for review to show that there is no non-facet pathology. 
 
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of trials of conservative therapy. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64490, 64491) for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Ketamine (J3490). 
 
You asked the Plan to pre-approve Ketamine. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical necessity rules for coverage of the requested 
drug have not been met because the drug has been prescribed for treatment of an off-label and not medically 
accepted indication. 
 
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 Ketamine. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of chronic regional pain syndrome. The FDA has not stated that the requested drug is 
indicated for the enrollee's condition. However, the Medicare-approved drug compendium DrugDex indicates 
that the requested drug has received an Orphan Drug designation, considered a positive citation, for the noted 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ketamine have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Ketamine (J3490).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the enrollee has a history of atrial fibrillation and bradycardia, there 
is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other 
apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in the enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).