Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Neupogen (J1442). 
 
You asked the Plan to pre-approve Neupogen. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that step-therapy rules for the requested drug have not 
been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Neupogen. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
available documentation states that the enrollee has been on both Zarxio and Nivestym. The provider no longer 
has access to these medications due to vendor not having them available. The enrollee has their next injections 
in 2 days and has had 2 injections while waiting for authorization. The enrollee has been on this type of 
medication for over 2 years. Step therapy may only be applied to new prescriptions or administrations of Part B 
drugs for enrollees that are not actively receiving the affected medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neupogen have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Neupogen (J1442).  
 
  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 a non-therapeutic continuous glucose monitor (CGM) 
transmitter (A9277) and sensor (A9276). 
 
You asked the Plan to pre-approve a non-therapeutic CGM transmitter and sensor. You say that your blood 
sugar goes up and down like crazy. You received a new pump that is paired up with the CGM and it would 
make it easier to monitor your blood sugar. You have been on a pump for 13 years and this newer Medtronics 
pump has this feature which makes things easier for you. You need this CGM monitor and sensor to be more 
helpful with monitoring your blood sugar as you are a type 1 diabetic. The Plan denied your request. The Plan 
says as the request is for a CGM transmitter and sensors that do not meet the definition of durable medical 
equipment, the Plan has determined that criteria for medical necessity have not been met and the request for 
coverage of non-therapeutic continuous glucose monitor transmitter and sensor cannot be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a non-therapeutic CGM transmitter and sensor have not been met. Specifically, the requested CGM 
device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic 
continuous glucose monitor (CGM) transmitter (A9277) and sensor (A9276).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care from October 28, 
2022, and forward. 
 
You asked the Plan to pre-approve continued inpatient mental health care from October 28, 2022, and forward. 
You say that continued inpatient mental health care from October 28, 2022, and forward is medically 
necessary. The Plan denied your request. The Plan says continued inpatient mental health care from October 
28, 2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continued inpatient mental health care 
from October 28, 2022, and forward. Our reviewer says that continued inpatient mental health care from 
October 28, 2022, and forward is not medically necessary. Our physician reviewer found this enrollee did not 
appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others and does not have auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve the enrollees condition or for the purpose of diagnosis beyond the date in question. I am unable to 
find an individualized treatment plan however the entire record is not present. It did appear that the records 
were supervised and evaluated by a physician. She was cooperative/compliant with treatment while not 
showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health care from October 28, 2022, and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient 
mental health care from October 28, 2022, and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found when treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. IGRT for superficial electronic 
brachytherapy is not specifically endorsed by the American College of Radiology (ACR)-American Society for 
Therapeutic Radiology and Oncology (ASTRO) Practice Parameter for Image-Guided Radiation Therapy. To 
bill for daily simple simulations and/or IGRT for a technology for which need has not been established by 
published data or supported by consensus guidelines is not the standard of care and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve image-guided radiation therapy (IGRT). You say that the enrollee is older 
and scared of a skin cancer diagnosis and would like to start treatment as soon as possible. The Plan denied 
your request. The Plan says the request does not meet the Medicare or health plan coverage 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 image-guided radiation therapy (IGRT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is 
generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations and/or IGRT 
for a technology for which need has not been established by published data or supported by consensus 
guidelines (many of which recommend against treatment with these devices in general- citations below) is not 
necessary. Our reviewer's decision is unfavorable as billing for daily simulations or IGRT would not be 
furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image-guided radiation therapy (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy fields 
(G6001).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cochlear implantation is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have hearing 
loss in the left ear and restricted hearing int he right ear. The records do not support that you have profound 
hearing loss defined by test scores of less than or equal to 40 percent correct in the best-aided listening 
condition on tape-recorded tests. The criteria for coverage are not met and the services are not reasonable or 
medically necessary at this time. 
 
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 a cochlear implant.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulator trials are covered for specific 
conditions. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the documentation supports that the requested services are medically reasonable and 
necessary. Our physician reviewer found the enrollee has chronic low back from spinal stenosis with 
neurogenic claudication. The enrollee is status post L2-L4 laminectomy with ongoing pain. The enrollee takes 
Tylenol, Lyrica and Voltaren Gel. The enrollee has tried ice/heat and physical therapy. The enrollee was seen 
and cleared by a psychologist. The documentation supports that the enrollee meets 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 a spinal cord stimulator trial have been met. Therefore, we decided that the Plan 
has to pre-approve a spinal cord stimulator trial.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral reduction mammoplasty. 
 
You asked the Plan to pre-approve bilateral reduction mammoplasty. 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 follows Medicare rules. Medicare rules say that reduction mammoplasty is only covered for certain 
indications. 
 
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 bilateral reduction mammoplasty. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has macromastia. The provided record does not document 
the presence of intertrigo unresponsive or recurrent despite conservative therapy or the presence of objective 
physical signs secondary to macromastia. The record does not indicate the existence of functional impairment. 
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 bilateral reduction mammoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bilateral reduction mammoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoe for multi-density inserts (A5500) and a 
multiple density insert, custom mold (A5513) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that your podiatrist as well as your 
doctor feel the shoes are necessary for your health. You are in extreme discomfort without shoes and would 
like them to be more mobile. The requested provider has been the only DME company that has been receptive 
to working with plan. The Plan denied your request. The Plan says medically necessary care is available 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 
diabetic shoe for multi-density inserts (A5500) and a multiple density insert, custom mold (A5513) to be 
provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent of genicular nerve 
branches (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent of genicular nerve branches. You say that 
the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested services are experimental/investigational. 
 
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 destruction by neurolytic agent of 
genicular nerve branches. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident 
regarding the results from the bilateral genicular nerve blocks on October 27, 2022. Moreover, there is a lack of 
large-volume, long-term, peer-reviewed outcome studies to support the use of these procedures for the enrollee. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent of genicular nerve branches have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent of genicular 
nerve branches (64624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is little evidence in the 
medical literature to suggest that this is an appropriate procedure for enrollee's back pain. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion] 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 encephalopathy and urinary tract infection. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy at an in-network benefit level to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this service is available by a provider in your network. However, if you 
choose to receive services from this out of network provider, your share of the cost for your covered services 
may be higher. There is no reason why you do not want to use the in-network provider and there is no medical 
reason to why you must use the out of 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 
occupational therapy at an in-network benefit level to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction of tooth #26 (D7140), the surgical 
extraction of tooth #21, 22, 27, 28, and 29 (D7210), alveoloplasty (D7311), and the removal of torus palatinus 
(D7472). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says alveoloplasty (D7311) and the removal of torus palatinus (D7472) are 
not covered by your dental benefits. The Plan also says that your benefit for extractions has been exhausted. 
 
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, alveoloplasty and the removal of torus 
palatinus are not among those covered under this benefit. The record shows the Plan approved three extractions 
on this authorization request, therefore, your benefit for extractions has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an extraction of tooth #26 (D7140), the surgical extraction of tooth 
#21, 22, 27, 28, and 29 (D7210), alveoloplasty (D7311), and the removal of torus palatinus (D7472).