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

 
We decided that the Plan does not have to pre-approve insertion of peripheral or gastric neurostimulator pulse 
generator or receiver, direct or inductive coupling (CPT code 64590). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because the enrollee's records do not show the 
outcome of the trial stimulator. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has fecal and urinary incontinence. The record indicates 
that the enrollee underwent a stimulator trial. The record provided does not indicate the results of the trial. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of peripheral or gastric neurostimulator pulse generator or receiver, direct or 
inductive coupling (CPT code 64590).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto 20MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Xarelto is a self-administered and does not fall under Part B coverage. 
 
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 Xarelto 20MG tablet.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compounded clonidine powder. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says compounded clonidine powder prescription is a self-administered and does not fall 
under Part B coverage. 
 
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 compounded clonidine 
powder.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block services. 
 
You asked the Plan to pre-approve genicular nerve block services. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
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 genicular nerve block services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations 
are considered investigational and not medically necessary for the treatment of chronic knee pain, including, 
but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment 
prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are 
not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are 
considered experimental/investigational in nature. The requested left genicular nerve block is not reasonable or 
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 genicular nerve block services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty power scooter. 
 
You asked the Plan to pre-approve these services. You say that you have an amputated leg and need a larger 
scooter. The Plan denied your request. The Plan says the services are not covered. 
 
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 heavy duty power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit package for a power wheelchair. 
 
You asked the Plan to pre-approve a transit package. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 transit package for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision, Excess Skin and Subcutaneous Tissue; 
Abdomen, Infraumbilical Panniculectomy (15830). 
 You asked the Plan to pre-approve the surgical procedure. You say that you are appealing because you are in 
constant pain with back and neck procedures because your body is a small frame and your abdomen is too big 
and interferes with your breathing and daily life activities. The Plan denied your request. The Plan says the 
records do not show that the medical necessity coverage criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found in this case, the record indicates that the enrollee desires weight loss and has a protuberant 
abdomen and desires cosmetic intervention. The record provided does not establish the medical necessity of the 
requested procedure. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical 
Panniculectomy (15830).
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 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 criteria for coverage are not met. Our physician reviewer found there is no documentation that you have a 
personal mobility deficit that impairs your ability to participate in mobility-related activities of daily living 
(MRADLs) within the home. There is no documentation that you are unable to be helped by the use of a cane 
or walker. There is no documentation that you can safely operate a power mobility device in your home nor do 
records document that your home provides adequate access for safe operation of the requested device. The 
power scooter is therefore not reasonable or 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 a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466) and humidifier, heated, used with positive airway pressure device 
(E0562). 
 
You asked the Plan to pre-approve a ventilator. You say that you are appealing the denial of the non-invasive 
home ventilator to be used for the treatment of COPD. The Plan denied your request. The Plan says the records 
do not show that the enrollee meets the criteria for a portable ventilator at this time. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe COPD and likely has 
chronic hypercapnic respiratory failure, based on a recent VBG, and an ABG in 2018, although there is no 
ABG done as an outpatient while stable. The enrollee may benefit from BiPAP with the AVAPS mode during 
sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466) and humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urine management system coded as K1006, A4328, 
A4329 and A5102. 
 
You asked the Plan to pre-approve a urine management system. You say that you have chronic urinary tract 
infections. During your recent hospital stay this system was used on you and it prevented the infection form 
getting worse. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a urine management system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a urine management system coded as K1006, A4328, A4329 and A5102.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the repeat ESI. You say that the requested injection is medically necessary. 
The Plan denied your request. The Plan says the prior injection did not provide sufficient duration of pain 
relief. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESIs may be covered when prior treatments 
provided at least three months of 50% or greater pain relief.  
 
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 repeat ESI. Our reviewer says that 
the requested ESI is not considered reasonable and necessary. Our physician reviewer found the enrollee is a 
female with right lower extremity radiculopathy thought to be originating from her L5/S1 vertebral level. Her 
physician performed an epidural steroid injection on 5/20/2022. The pain relief was approximately 70% for 5-7 
days. The requirement for a second epidural steroid injection is that the pain relief from the first injection be at 
least 50% for at least 3 months, or the physician will attempt the second injection using a different approach 
and/or medication.  The medical necessity for a second ESI is not documented in the medical record. 
 
  
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the use of this drug 
is not reasonable and 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 Keytruda. Our physician reviewer 
found that the record indicates that the enrollee has a diagnosis of metastatic basaloid squamous cell carcinoma 
of the tonsil. The record indicates that the PDL-1/CPS score is less than one and there is no documentation of 
MSI instability or actionable mutations. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the 
use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer 
journals were submitted for review. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional home health physical therapy visits. 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. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 8 additional home health physical 
therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
you do not have documented, ongoing, home health physical therapy needs. There is no evidence that home 
health physical therapy is needed to treat an acute illness or injury. Your care needs appear to be custodial. As 
such, home health physical therapy is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural injection of Hylenex for lysis of adhesions. 
 
You asked the Plan to pre-approve the epidural injection. You say that this is a medically necessary procedure. 
The Plan denied your request. The Plan says this is an experimental treatment. 
 
The Plan follows Medicare rules. Medicare rules say that epidural injections of substances not FDA designated 
for epidural injection use are not covered. The rules indicate that only medically reasonable and necessary 
services may be 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 epidural injection. Our reviewer 
says that the requested treatment is not considered reasonable and necessary. Our physician reviewer found the 
enrollee is a 78-year-old male with low back pain due to lumbar radiculopathy, lumbar facet syndrome, and 
lumbar internal disc disruption. The provider has requested a caudal epidural lysis procedure with Hylenex to 
address the enrollee's symptoms of low back pain.  
The clinical value and effectiveness of caudal epidural lysis procedure with Hylenex in the setting of lumbar 
radiculopathy, lumbar facet syndrome, and lumbar internal disc disruption, as with this enrollee, have not been 
demonstrated in the peer-reviewed literature. 
 
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 epidural injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve epidural injection of Hylenex for lysis of adhesions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and manual swingaway. 
 
You asked the Plan to pre-approve a power wheelchair and manual swingaway. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested items. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollee's condition can be improved by a four wheeled walker. In addition, the 
documentation does not support that the enrollee has wheelchair accessible housing for the requested power 
wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and manual swingaway.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), Freestyle Libre 
14 Day System. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee is on the maximum dose of Metformin. 
You say that the enrollee will start Farxiga as well. You also say that the enrollee requires the requested CGM 
to manage their diagnosis twice daily and as needed. The Plan denied your request. The Plan says the requested 
CGM is not medically reasonable or necessary. 
 
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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor (CGM), Freestyle Libre 14 Day System.