Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a laryngoscopy (31570) with Botox injection. 
 
You asked the Plan to pre-approve a laryngoscopy with Botox injection. The Plan denied your request. The 
Plan says that the enrollee does not have a condition that supports medical necessity, and the requested 
laryngoscopy with Botox injection into the vocal cords is denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 
Medicare rules also 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 a laryngoscopy with Botox injection. 
Our reviewer says that a laryngoscopy with Botox injection is medically reasonable and necessary for the 
enrollee. Our physician reviewer found the records provided demonstrate that Botox will be the drug used in 
the vocal cord injection portion of the laryngoscopy being requested. The enrollee has a diagnosis that supports 
the medical necessity of the service in dispute. Our reviewer found that the requested use of Botox is FDA-
approved for the enrollee's diagnosis. Our physician reviewer also found that the documentation supports 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 a laryngoscopy with Botox injection have been met. Therefore, we decided that 
the Plan has to pre-approve a laryngoscopy (31570) with Botox injection.  
 
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 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 that the records show you have a history of falls. You do not have a functional impairment that limits your ability to complete mobility-related activities of 
daily living (MRADLs) in the home. The power scooter is therefore 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 power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve half leg appliances for a pneumatic compression device 
(PCD). 
 
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 PCD appliances are 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 that PCD accessories are only covered 
when the appropriate, related PCD base (E0675) meets the coverage criteria. The enrollee does not have a 
diagnosis of arterial insufficiency. The criteria for coverage of the PCD base are not met; therefore, the half leg 
appliance is also 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 half leg appliances for a pneumatic compression device (PCD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 (Breast Cancer 1 and Breast 
Cancer 2) gene testing. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 gene testing. You say that this test is medically 
necessary, because if you have this cancer, it could be life-threatening. The Plan denied your request. The Plan says this test is not covered in enrollees with no personal history of cancer. It is considered a screening test in 
this case and is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA1 and BRCA2 gene testing, is being requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes or for those who have no personal 
history of cancer. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 
(Breast Cancer 1 and Breast Cancer 2) gene testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 You asked the Plan to pre-approve Ilumya. You say that with Ilumya, the enrollee only needs to come in for 
their injection four times per year, and does not have to deal with the hassle of using a specialty pharmacy or 
injecting themself. The Plan denied your request. The Plan says this request does not meet the Plan's Part B 
step therapy criteria for Ilumya. 
 
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 Ilumya. Our reviewer says that the 
enrollee does not meet the coverage criteria for Ilumya. Our physician reviewer found the enrollee has not tried 
and failed the Plan's required drug. Our reviewer also found that the documentation does not support that the 
required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: Step-Therapy
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 needs this medication. The Plan denied 
your request. The Plan says you must first try to be unable to use the the referred medications including, 
Feraheme, Ferrlecit, Infed, or 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 
indicate that the enrollee has tried and failed the preferred drugs. The reviewer found that there is no 
documentation provided indicating that the plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc services. 
 
You asked the Plan to pre-approve Via Disc services. You say that the documentation provided supports that 
the requested procedure is appropriately indicated for the enrollee. The Plan denied your request. The Plan says 
the requested services are not considered medically reasonable and necessary. The Plan says that a review of 
the current medical literature does not consider this service to be standard medical treatment for the enrollee's 
condition. 
 
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 Via Disc services. Our reviewer says 
that Via Disc services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via Disc allograft is experimental. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via Disc services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Via Disc services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0315U) provided on September 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0315U) provided on 
September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level) (0627T). 
 
You asked the Plan to pre-approve the VIA Disc NP procedure. You say that the denial for this procedure is 
unwarranted and unsupported by the enrollee's current medical status and is inconsistent with currently 
accepted medical practice. 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 your back pain. It is not an accepted standard of 
medical practice for the diagnosis or treatment of 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 VIA Disc NP procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/ investigational procedure. Therefore, 
the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the VIA Disc NP procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level) (0627T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no agreement that the 
tests should be included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair (TMVR). 
 
You asked the Plan to pre-approve TMVR. 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 follows Medicare rules. Medicare rules say that Transcatheter Edge-to-Edge Repair (TEER) for 
Mitral Valve Regurgitation 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 TMVR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the records provided do not show that the 
enrollee is under the care of a heart team comprising a cardiac surgeon, interventional cardiologist, and 
interventional echocardiographer. In addition, the suitability of surgical mitral valve repair has not been 
addressed. As such, Medicare guidelines would not support TMVR in this setting. In summary, TMVR would 
not be considered reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter mitral valve repair (TMVR).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is an emergency and a medically necessary test. 
Your back pain is interfering with your work and sleep. The Plan denied your request. The Plan says the 
request for an MRI is not medically necessary at this time. 
 
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 
request is not medically necessary. Our physician reviewer found that you have back pain. The record provided 
does not document the presence of red flag signs or symptoms or an abnormal neurologic examination. The 
record does not indicate that a trial of conservative therapy has been tried and failed. 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the lumbar spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you live alone and have concerns you will break 
something from a fall. The Plan denied your request. The Plan says based on guidelines and the information we 
have about your condition; you don't meet the requirements for skilled nursing facility. You can receive the 
care you need in another setting, a long-term care facility, or other outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote neuromonitoring (95861, 95870) provided on 
September 1, 2022. 
 
You asked the Plan to pay for the remote neuromonitoring. You say that the service should be covered. The 
Plan denied your request. The Plan says this is not an approved service for the members diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the diagnosis of D36.16 Benign neoplasm of 
peripheral nerves and autonomic nervous system of pelvis is not a medically supported diagnosis when billing 
with Current procedural Terminology (CPT) code CPT 95861 and 95870. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the remote neuromonitoring have not been met. Therefore, we decided that the Plan does not have 
to pay for the remote neuromonitoring (95861, 95870) provided on September 1, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
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 that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found that the enrollee has knee osteoarthritis. 
The Food and Drug Administration (FDA) stated that the drug is indicated as an intra-articular injection for the 
treatment of osteoarthritis-related knee pain. The services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve Zilretta.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Auricular Stimulator (64555, L8679). 
 
You asked the Plan to pre-approve the Auricular Stimulator. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered. Acupuncture for stimulation of auricular points is not a 
covered Medicare benefit. Code 64555 does not describe the procedure of auricular acupuncture stimulation. It 
should be billed using code 64999 - unlisted procedure, nervous system. 
 
We looked at the file and Medicare rules. The device at issue is considered an auricular stimulator and is not a 
covered device. Based on this information, we decided that Medicare rules for coverage of the Auricular 
Stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Auricular 
Stimulator (64555, L8679).