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

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve Opzelura. You say that this is for continuation of successful therapy. You 
also say that changing this medication could jeopardize the improvement that the enrollee has achieved with 
Opzelura. The Plan denied your request. The Plan says Opzelura is not covered under the enrollee's plan. The 
Plan also says that non-injectable, self-administered drugs like Opzelura are covered by the pharmacy (drug) 
benefit. 
 
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 Opzelura.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that medical criteria for a LTACH admission 
have been met. The Plan denied your request. The Plan says enrollee is receiving appropriate in-patient acute 
care and does not require transfer to a LTACH. 
 
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 a transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care setting. 
 
   
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261). 
 
You asked the Plan to pre-approve a CT colonography. You say that a virtual was never done, and you would 
like this test to be approved for coverage. The Plan denied your request. The Plan says the requested service is 
not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a CT colonography is indicated in those patients in 
whom a diagnostic optical colonoscopy of the entire colon is incomplete, and for the evaluation of a 
submucosal abnormality detected on colonoscopy or other imaging study. 
 
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 computed tomographic colonography. 
Our reviewer says that a computed tomographic colonography is not reasonable and necessary for the enrollee. 
Our physician reviewer found the available record does not support failed colonoscopy on December 29, 2015. 
Specifically, the exam was complete to the cecum and aside for a suboptimal preparation there were not 
limiting conditions such as an obstructing neoplasm, stricture, tortuosity, spasm, redundant colon diverticulitis, 
extrinsic compression or aberrant anatomy scarring from prior surgery. Our reviewer found that the provider 
described the procedure as technically "not difficult", so available records do not support that optical re-
colonoscopy cannot be safely attempted with an ideal preparation. Our physician reviewer also found that no 
submucosal abnormalities were described in 2015 to warrant a computed tomographic colonography in lieu of 
optical examination in the enrollee's 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 a computed tomographic colonography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that a power scooter is necessary for activities 
outside of your home. The Plan denied your request. The Plan says the criteria for coverage for the power 
scooter have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered annually. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 9, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on July 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 
You asked the Plan to pre-approve Monoferric. You say that the requested Monoferric is medically necessary. 
The Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer. 
 
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 Monoferric. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Infed 
and Venofer first before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drug(s). There is no documentation provided indicating that the Plans 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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breasts (77049). 
 
You asked the Plan to pre-approve an MRI of the breasts. You say that this imaging is medically necessary as 
the enrollee has a previous history of breast implants rupturing and a family history of breast cancer. Because 
of this, the enrollee is unable to have standard mammograms. The Plan denied your request. The Plan says that 
this MRI is not medically necessary as the enrollee has had a bilateral mastectomy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the breasts. Our reviewer 
says that the requested imaging service is medically necessary and reasonable. Our physician reviewer found 
that the records show a very strong family history of breast cancer for which the enrollee had a prophylactic 
mastectomy in 1984. While there has been no calculation of lifetime risk of breast cancer in the records, the 
family history indicates a very high possibility if the Gail risk model or the Tyler-Cuzick model were used. 
While the enrollee has had a bilateral mastectomy, the truth is most of these patients will have a small amount 
of remaining breast tissue and that tissue is subject to the same elevated risk as the removed breasts. The 
presence of implants is not a contraindication to mammography, and the very strong family history is reason 
enough for the requested MRI. The requested MRI will provide the added benefit of implant evaluation. The 
requested study should 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 an MRI of the breasts have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) of the breasts (77049).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this procedure is medically 
reasonable following the enrollee's elective surgery. The Plan denied your request. The Plan says there is no 
medical need for the enrollee to be admitted to the inpatient hospital with the requested elective surgery 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee is an 82-year-old male with a diagnosis of left shoulder 
pain. The enrollee has been approved for a left reverse total shoulder arthroplasty. The procedure is currently 
approved as an ambulatory procedure. There is no documentation provided to support the expectation the 
enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show 
that inpatient hospital services are medically necessary for the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of an implant on tooth #5 (D6010) and a 
bone graft at the time of implant placement (D6104) provided on April 21, 2022 
 
You asked the Plan to pay for the dental services. You say that you are not getting your Notices of Denial of 
Payment sent to the correct address. You say you have been trying to resolve this issue for several years. The 
Plan denied your request. The Plan says the claim was processed correctly. The services are not covered under 
your dental benefit. 
 
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 surgical 
placement of an implant on tooth #5 (D6010) and a bone graft at the time of implant placement (D6104) 
provided on April 21, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an 
admission to a LTACH to regain maximum level of functions to be able to return home safely. You say that the 
enrollee requires daily physician monitoring due to their complex medical needs. The Plan denied your request. 
The Plan says an LTACH admission is not medically necessary. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care setting. 
 
   
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee has not been on this treatment for over 
365 days. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Infed and Venofer. 
 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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that the enrollee has tried and failed the plan's step one alternatives. The reviewer also found that there 
is no indication that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternatives. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
 
 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 Prolia. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Prolia. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) services. 
 
You asked the Plan to pre-approve SBRT services. You say that this procedure is considered medically 
reasonable and necessary. The Plan denied your request. The Plan says that SBRT is not a standard of care for 
oligometastatic breast cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SBRT services. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT is generally indicated for patients with oligometastatic disease of 
for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a state of 
metastatic disease with metastases few in number and extent. The benefit of SBRT perhaps remains 
controversial, particularly in light of the recent negative NRG BR002 study (Chmura et al. presented as 
American Society of Clinical Oncology in 2022) that showed no benefit with respect to progression free 
survival in women treated with standard of care systemic therapy with or without SBRT for breast cancer 
oligometastases to any site. However, this study was not specific to spine metastases for which the Canadian 
SC24 data shows a benefit with SBRT. The recent Canadian SC24 study randomized 229 patients to 
conventional external beam radiotherapy (n=115) or stereotactic body radiotherapy (n=114). Stereotactic body 
radiotherapy at a dose of 24 gray (Gy) in two daily fractions was superior to conventional external beam 
radiotherapy at a dose of 20 Gy in five daily fractions in improving the complete response rate for pain. In 
summary, despite mixed data, based on ASTRO/ESTRO consensus guidelines, SBRT would be considered to 
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 SBRT services have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy (SBRT) services.  
 
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 pay for the oral evaluation (D0120), intraoral radiographic image 
(D0220 and D0230), bitewings (D0274), and prophylaxis (D110) provided by an OON provider on May 19, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you saw the same dentist last year and the 
services were paid with no problem. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the oral evaluation (D0120), intraoral radiographic image (D0220 and D0230), bitewings (D0274), 
and prophylaxis (D110) provided by an OON provider on May 19, 2022.