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

 
We decided that the Plan does not have to pre-approve nasal endoscopy with a bilateral ClariFix procedure, 
with possible Acclarent Relieva tract. 
 
You asked the Plan to pre-approve nasal endoscopy with a bilateral ClariFix procedure, with possible Acclarent 
Relieva tract. 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 nasal endoscopy with a bilateral 
ClariFix procedure, with possible Acclarent Relieva tract. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
has a diagnosis of Vasomotor rhinitis. The enrollee has a constant runny nose, mostly activated by eating. 
Symptoms have improved, but have not resolved with saline rinses as needed, fluticasone twice daily, and 
ipratropium bromide three times daily. There is insufficient evidence regarding the long-term benefits of the 
requested procedures, and the procedures have not been compared with other treatment modalities. 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 nasal endoscopy with a bilateral ClariFix procedure, with possible Acclarent 
Relieva tract have not been met. Therefore, we decided that the Plan does not have to pre-approve nasal 
endoscopy with a bilateral ClariFix procedure, with possible Acclarent Relieva tract.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not for treatment of a non-healing long bone fracture. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
 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 stimulator. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found that detailed 
documentation is not evident regarding serial radiographs failing to demonstrate signs of progressive healing of 
the scaphoid fracture. Additionally, there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested electric bone growth stimulator, 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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteogenesis stimulator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an advanced foot with ankle feature and other 
parts for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that criteria may be met for a simpler K2 foot feature. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that a prosthetic clinical dated on 6/17/22 indicates that the enrollee uses a walker and wheelchair for 
mobility. This would indicate that the enrollee has the potential to be a K3 ambulator. The enrollee's motor 
strength is noted to be 5/5 in the right lower extremity and 5/5 in the left lower extremity except for below the 
knee. The enrollee is noted to be able to stand with a walker with single limb support and has undergone pre-
prosthetic therapy. The documentation provided does support the use of the requested K3 level prosthetic foot. 
Therefore, the Freedom Innovations Kinterra prosthetic foot is 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 services have been met. Therefore, we decided that the Plan has to pre-
approve a prosthetic leg with an advanced foot with ankle feature and other parts for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a connective tissue grafting procedure described by 
code D4273. 
 
You asked the Plan to pre-approve the grafting procedure. You say that you believe that this should be covered 
as your dental health requires it. The Plan denied your request. The Plan says this is not a covered benefit under 
your dental coverage. 
 
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 pre-approve a 
connective tissue grafting procedure described by code D4273.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system, tilt only (Current Procedural 
Terminology (CPT) code E1002). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can functionally shift weight in the wheelchair and does not need power tilt. 
 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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the ddocumentation does not reveal that the patient has spasticity, utilizes intermittent 
catheterization, or is at high risk of skin breakdown. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seating system, tilt only (Current Procedural Terminology (CPT) code E1002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0668, 
E0656). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no trial of E0650 or E0651. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that as the records do not document trial and failure of a standard pneumatic compression pump, then it 
cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump. The provided records do not document trial and failure of four weeks of regular, daily, 
multiple-hour home usage of a standard pump (E0650 or E0651) after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the device as required by 
the Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829). 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0668, E0656).
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 intense rehabilitation for recovery. 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 your medical status does not require intensive physician and nursing oversight in an 
IRF.  While you may benefit from additional multiple therapies, including physical and occupational therapy, the 
documentation does not reveal that you require this therapy on an intensive IRF level. 
 
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 prosthetic leg and accessories to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve a prosthetic leg and accessories. You say that the provider that has been 
referred does not know how to fix your leg. The Plan denied your request. The Plan says the medically 
necessary care is available with providers in-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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a prosthetic leg and accessories to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the therapy to maintain functioning in your 
legs. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 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 enrollee is medically stable and does not need PMR physician's supervision 3 times a week in an IRF. No acute rehab nursing needs identified or documented. At the current functional level, 
the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach in an IRF. The documents does not support necessity for admission 
to an IRF. While the enrollee may benefit from continued physical therapy and occupational therapy, the 
enrollee's rehab needs can be safely provided in a lower intensity and alternate setting such as in an SNF with 
similar outcome as in IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage. 
 
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 
Keytruda is not reasonable and necessary for the enrollee. Our physician reviewer found the FDA 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. Our reviewer found that no literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (Keytruda).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services can be provided by a network 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 
acupuncture services 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 power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that you disagree with the denial of 
the requested wheelchair feature. The Plan denied your request. The Plan says these systems are not covered by 
Medicare because they are not primarily medical in nature. 
 
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 power seat elevation feature (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility IRF admission and 
services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care as you are in pain, can't walk and 
are trying to get pain medication. The Plan denied your request. The Plan says based on a review of the clinical 
information received, it was determined that you are medically stable and the criteria for coverage 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 you were admitted for hip pain. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electron beam computed tomography (EBCT) to 
measure coronary calcification. 
 
You asked the Plan to pre-approve the EBCT. You say that this test is necessary to determine the enrollee's 
medication. The Plan denied your request. The Plan says the requested EBCT 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 the EBCT. Our reviewer says that the 
requested EBCT is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient support in the peer-reviewed literature demonstrating a significant benefit of CT 
imaging of the heart with quantitative evaluation of coronary calcium in guiding optimal management of this 
patient. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary 
calcium is considered experimental/investigational for the evaluation and management of the enrollee's medical 
condition. Therefore, the reviewer found that the requested service 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 EBCT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electron beam computed tomography (EBCT) to measure coronary calcification.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the chest for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was a study similar to this one that was recently performed. 
 
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 the services. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there is no 
pneumothorax or effusion seen on the July computed tomography (CT). Since then, no plain x-rays have been 
done. A repeat scan would not be appropriate without any plain x-rays done. 
 
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 computed tomography (CT) of the chest for the enrollee.