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

 
We decided that the Plan does not have to pre-approve Zinplava. 
 
You asked the Plan to pre-approve Zinplava. You say that this drug is medically necessary for the enrollees 
condition. 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zinplava. Our reviewer says that the 
requested drug, Zinplava, is not medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of recurrent Clostridium difficile colitis. The record indicates that the 
requested drug is being used as monotherapy for the enrollee's condition. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. 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 Zinplava have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Zinplava.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this HFCWOD is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the provided records do not show that 
enrollee has diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically reasonable and necessary. Our physician reviewer found that this enrollee has a cough and difficulty raising mucus. There is no diagnosis of cystic fibrosis, bronchiectasis, or 
neuromuscular disease. There is no indication that the patient uses a cough-assist device. The enrollee does not 
have a diagnosis for which HFCWOD has been shown to be effective, and there is no evidence the enrollee has 
tried and failed other airway clearance measures. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes sent in do not meet the brain MRI guidelines. 
 
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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the enrollee has had 
progressive short-term memory loss over the past year at least. The enrollee has diabetes mellitus. MRI has 
been requested to evaluate the brain and is reasonable. The history favors Alzheimer's disease and MRI is the 
procedure of choice for evaluation especially of the hippocampus. Despite the lack of neurological symptoms 
the progressive memory loss is a valid indication for the requested MRI. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain.  
 
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 bone replacement graft (D4263, D4264, and D7953) 
and guided tissue regeneration (D4266) for tooth #2, #3, #12, and #14. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get 
these dental procedures done because of your gum disease. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because bone replacement grafts and guided tissue 
regeneration are not covered by the Plan 
 
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 
bone replacement graft (D4263, D4264, and D7953) and guided tissue regeneration (D4266) for tooth #2, #3, 
#12, and #14.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab (Tecentriq), albumin-bound Paclitaxel 
(Abraxane), and Bevacizumab-bvzr (Zirabev). 
 
You asked the Plan to pre-approve Atezolizumab (Tecentriq), albumin-bound Paclitaxel (Abraxane), and 
Bevacizumab-bvzr (Zirabev). You say that the requested Atezolizumab (Tecentriq), albumin-bound Paclitaxel 
(Abraxane), and Bevacizumab-bvzr (Zirabev) are medically necessary. The Plan denied your request. The Plan 
says the requested Atezolizumab (Tecentriq), albumin-bound Paclitaxel (Abraxane), and Bevacizumab-bvzr 
(Zirabev) are 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 Atezolizumab (Tecentriq), albumin-
bound Paclitaxel (Abraxane), and Bevacizumab-bvzr (Zirabev). Our reviewer says that the requested 
Atezolizumab (Tecentriq), albumin-bound Paclitaxel (Abraxane), and Bevacizumab-bvzr (Zirabev) are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of 
non-operable adenocarcinoma of the lung, PD-L1 level 35%.  The record indicates that the enrollee has failed 
previous chemotherapy. 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 do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved 
cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 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 Atezolizumab (Tecentriq), albumin-bound Paclitaxel (Abraxane), and 
Bevacizumab-bvzr (Zirabev) have not been met. Therefore, we decided that the Plan does not have to pre-
approve Atezolizumab (Tecentriq), albumin-bound Paclitaxel (Abraxane), and Bevacizumab-bvzr (Zirabev).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 13, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you were told there would be no payment due 
after your procedure. You would like the Plan to make a one-time exception and make payment for this claim. 
The Plan denied your request. The Plan says the claim was processed correctly. Your dental benefit package 
does not allow coverage of code D4910. 
 
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 
periodontal maintenance (D4910) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited (problem-focused) oral examination (D0140) 
provided on July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the services you received to be 
covered by the Plan. The Plan denied your request. The Plan says the claim was processed correctly. Your 
contract clearly indicates that the oral exam you received is not covered under your dental benefit policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
(problem-focused) oral examination (D0140) provided on July 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional fifteen physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional fifteen PT visits. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 additional fifteen PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills 
of a professional therapist are required to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The enrollee should be able to transition to an independent home program at this point. The requested 
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
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 additional fifteen PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional fifteen physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre and supplies. 
 
You asked the Plan to pre-approve a FreeStyle Libre and supplies. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre and supplies.
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 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 the documentation shows that the enrollee has functional impairments but there are 
no complex functional deficits specified thus would not require intense therapy or interdisciplinary team 
management of rehabilitation in an IRF setting. There are no active medical comorbidities thus the enrollee 
would not require continued inpatient hospitalization during rehabilitation. 
 
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: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the records do not show it is medically safe for the 
enrollee to go to a LTACH because they need continued treatment and care that can only be given in a hospital 
setting. Their continued care needs include continued care and treatment for the left leg and care for nausea and 
diarrhea. When the enrollee is ready to leave the hospital, they can safely receive this care 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 the enrollee was admitted with sepsis lower extremity cellulitis and soft tissue 
infection. The record indicates that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care.    The enrollee continues to receive acute care services, and these have not 
been denied.  The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 that the enrollee was admitted for weakness and falls. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. In this case, the enrollee does 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. In conclusion, there is not a reasonable expectation that this patient 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of thoracic spine without contrast (72146).
You asked the Plan to pre-approve an MRI of thoracic spine without contrast. You say that the requested service is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet coverage criteria.
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 thoracic spine without contrast. Our reviewer says that the service is medically necessary and reasonable. Our physician reviewer found the enrollee is noted to have a history of multilevel back pain. The enrollee is being scheduled for a selective nerve root block injection (SNRB) in the thoracic spine (per the records provided for review). It would be considered reasonable and necessary to have an advanced imaging study performed prior to performance of SNRB. Such imaging would be useful in guiding this course of treatment and indicating any potential contraindications to the procedure. In as much, as this request is consistent with standards of practice/care this would be reasonable and necessary 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 an MRI of thoracic spine without contrast have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of thoracic spine without contrast (72146).
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 the Medtronic Infuse BMP Allograft. 
 
You asked the Plan to pre-approve the Medtronic Infuse BMP Allograft. You say that this procedure should be 
approved due to worsening pain and numbness the patient has been experiencing. The Plan denied your 
request. The Plan says the Medtronic Infuse BMP Allograft is considered investigational. There is insufficient 
reliable evidence in the form of high-quality peer-reviewed medical literature to establish the safety and 
efficacy of the requested product for use in a posterolateral lumbar fusion procedure. 
 
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 Medtronic Infuse BMP Allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this 75-year-old female was being treated for radiculopathy of the 
lumbar region; spondylolisthesis of the lumbar region; spinal stenosis of the lumbar region with neurogenic 
claudication; and other spondylosis with radiculopathy of the lumbar region. She presented with progressively 
worsening central lower thoracic stabbing pain with intermittent radiation to the right buttock and into the 
posterolateral leg stopping at the calf where it feels like a sore bruise.  The exam reveals intact strength and sensation. However, 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. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Medtronic Infuse BMP allograft, 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 Medtronic Infuse BMP Allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Medtronic Infuse BMP Allograft.