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

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection services. 
 
You asked the Plan to pre-approve SI joint injection services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage 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 SI joint injection services. 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 multiple pain complaints including hip and post herpetic neuralgia. 
The progress notes SI joint tenderness but there is no documentation of at least 3 physical exam signs that show 
the pain is coming from the sacroiliac joint. In addition, there is no documentation of 6 weeks of conservative 
treatment with little to no improvement or if the injection is part of a comprehensive pain management 
program. As a result, the requested services are not 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 SI joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac (SI) joint injection services.
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 you need intense rehab because of muscle loss. You cannot walk, you have no core strength to raise yourself. The Plan denied your request. The Plan says the request is not medically necessary.

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 your medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair (E1399). 
 
You asked the Plan to pre-approve a recliner chair. You say that you suffer from chronic pain on your lower 
back. You have arthritis on your knees, which makes it very difficult to stand by yourself. The Plan denied 
your request. The Plan says Medicare says a recliner chair is not covered because it is considered a comfort or 
convenience item and 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 recliner chair (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab injections (J9299). 
 
You asked the Plan to pre-approve Nivolumab injections. You say that the drug is medically necessary. The 
Plan denied your request. The Plan says this drug is 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 Nivolumab injections. Our reviewer 
says that this drug is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of metastatic spindle cell sarcoma. 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 
does not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Nivolumab injections (J9299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the medical necessity for the bone 
marrow aspirate procedure has not been established after clinical review and per the peer-reviewed medical 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspirate is experimental. In this case, more research is needed 
before coverage can be approved.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hizentra. 
 
You asked the Plan to pre-approve Hizentra. You say that the enrollee has had shortness of breath with 
Gamunex. The Plan denied your request. The Plan says the enrollee has not tried and failed subcutaneous 
Gamunex-C. 
 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 Hizentra. Our physician reviewer found 
that the enrollee has chronic inflammatory demyelinating polyneuropathy (CIDP). The Plan requires a trial of 
Gamunex-C before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective 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 Hizentra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hizentra.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parenteral nutrition. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has protein calorie 
malnutrition. The Plan denied your request. The Plan says the enrollee does not have a permanent problem with 
their digestive tract. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplementation. Although these may 
be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve parenteral nutrition.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the enrollee has had a great response to the injection 
in the past. The Plan denied your request. The Plan says the enrollee has not tried one of the preferred drugs. 
 
 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 Supartz. Our physician reviewer found 
that the enrollee has primary osteoarthritis of the knee. The Plan requires a trial of Orthovisc, Synvisc, or 
Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee had a stroke and was independent prior. 
You say the enrollee's needs to transition to the next level of care at a rehab facility. The Plan denied your 
request. The Plan says that a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has new complex functional impairments and clinical assessment 
needs status post-acute cerebrovascular accident. Evaluating therapists recommended intense therapy however 
the enrollee concern is about being able to tolerate intense therapy. Clinical documentation shows that patient 
requires daily skilled services on an inpatient basis in a SNF.  
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane and Gemzar. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drugs 
are not supported for the enrollee's condition. 
 
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 the requested drugs. Our physician 
reviewer found that the enrollee has a metastatic neuroendocrine tumor. The requested use of Abraxane and 
Gemzar is not FDA approved for the enrollee's diagnosis. There is no biopsy confirming adenocarcinoma. The 
requested 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 requested drug is safe and 
effective and otherwise reasonable and necessary for this 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 the requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Abraxane and Gemzar.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panniculectomy and Abdominoplasty (15847, 15830). 
 
You asked the Plan to pre-approve the Panniculectomy and Abdominoplasty. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that when surgery is performed to alleviate such 
complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, 
or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory 
to usual standard medical therapy, such surgery may be considered reconstructive. 
 
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 Panniculectomy and 
Abdominoplasty. Our reviewer says that the requested procedure is not medically necessary. Our physician 
reviewer found the record provided does not document the failure of conservative treatment nor do the pictures 
provided support the presence of chronic intertrigo. The record provided does not document stable weights 
over time and does not document functional limitations. 
 
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 Panniculectomy and Abdominoplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Panniculectomy and Abdominoplasty (15847, 15830).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exploratory celiotomy (49000) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the exploratory celiotomy. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says there are 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 provider at issue in this case is not a network provider with the Plan. 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 exploratory celiotomy. Our reviewer says that the requested out-of-
network service is not medically necessary. Our physician reviewer found the service can safely and effectively 
be done by in-network provider. There are no unique aspects of 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 the exploratory celiotomy have not been met.  
 
The Plan has network providers available who can provide the services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve the exploratory celiotomy. Therefore, we decided that the 
Plan does not have to pre-approve an exploratory celiotomy (49000) to be provided by an out-of-network 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Protext umbilical cord allograft (skin substitute). 
 
You asked the Plan to pre-approve a Protext umbilical cord allograft (skin substitute). You say that the service 
is medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 Protext umbilical cord allograft (skin 
substitute). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found umbilical cord allograft application is not standard of care 
for the treatment of osteoarthritic pain. In fact, medical literature advises that this particular type of treatment 
for this medical diagnosis is experimental. Standard of care treatments for osteoarthritis of the ankle include 
bracing, activity modification, corticosteroid injections, anti-inflammatory medications, and possible ankle 
arthroscopy to remove synovitis and osteoarthritis if 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 a Protext umbilical cord allograft (skin substitute) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Protext umbilical cord allograft (skin 
substitute).
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 based on the enrollees current condition and 
functional deficits physicians have decided she requires intensive inpatient rehabilitation. The Plan denied your 
request. The Plan says the request is not medically necessary, the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that lumbar radiofrequency ablation (RFA) is medically 
necessary. The Plan denied your request. The Plan says you have had only one medial branch block (MBB) 
injection, which produced 50 percent relief. This does not meet Medicare criteria. 
 
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 pre-approve RFA. Our reviewer says that lumbar 
radiofrequency ablation (RFA) is not medically necessary. Our physician reviewer found in this case; you have 
had one MBB which provided 50% relief of pain. The review has determined that the requested lumbar RFA 
does not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve lumbar radiofrequency ablation (RFA).