Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the stress test provided on June 20, 2022. 
 
You asked the Plan to waive the cost share for the stress test. You say that you had a stress test. You say that 
the results showed you were positive for ischemia. You also say that you had to have the study done again on 
June 29, 2022. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   
You have been asked to pay a $100 copayment for the stress test. This service falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost share for the stress test provided on June 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that this injection is medically 
necessary. The Plan denied your request. The Plan says the patient does not meet criteria for the epidural 
steroid injection. 
 The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered only when the 
patient has lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis, post-laminectomy syndrome, or acute herpes zoster pain. 
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer 
found the documentation does not reveal objective evidence of lumbar radiculopathy on an imaging study or on 
a physical examination in the proposed level of injection. The patient has normal motor, sensation and reflexes 
in her lower extremities.  
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have exertional dyspnea and restrictive lung disease related to R diaphragmatic dysfunction, as 
well as obesity. There is a history of post-polio syndrome. There is no diagnosis of chronic obstructive 
pulmonary disease (COPD) or thoracic restrictive disease. There is no documentation of chronic carbon 
Dioxide (CO2) retention on arterial blood gases (ABG) done while stable. Medicare does not cover a home ventilator when used as bilevel positive airway pressure (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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is not covered by Medicare or the health plan. 
 
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 the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that in summary, it is safe to say that IMRT is not experimental, but rather a useful tool available to 
radiation oncologists to potentially reduce toxicity and improve the lung, heart and skin dose distributions. In 
light of the expected dosimetric improvement with IMRT in this patient who is to undergo chest wall and 
comprehensive nodal radiation, as well as ASTROs most recent update of its Choosing Wisely list, the 
decision would be favorable as IMRT would 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 the therapy have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation therapy (IMRT). 
  
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve an MRI of the abdomen. 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 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 abdomen. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you have no known 
predisposition to hepatocellular carcinoma (HCC) such as cirrhosis. Therefore, the requested MRI is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron-emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that this test is medically necessary. The Plan denied 
your request. The Plan says the requested PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the 
requested PET scan is not medically necessary. Our physician reviewer found this patient had a recent 
computed tomography (CT) scan of the lungs on September 28, 2022, that showed stable disease. There is no 
indication given for a PET scan 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron-emission tomography (PET) scan.
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 based on the enrollee's current condition, functional 
deficits and multiple comorbidities IRF admission criteria are met. The Plan denied your request. The Plan says 
the request 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 that in this case, the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in 
rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. The enrollee can receive further services at a lower level of care. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both Alzheimer disease (AD) and frontotemporal disorders (FTD). 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case the enrollee is 
only suspected of having AD. The notes provided for review indicated that the treating neurologist's impression 
is that the enrollee has AD. There was no mention in the records that support a suspicion of the member having 
FTD, let alone both AD and FTD simultaneously. In this context/setting, the initial requirement of the NCD for 
PET/CT for Dementia would not be met. Therefore, the request does not meet criteria for coverage. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this level of care. The Plan denied your 
request. The Plan says that the coverage criteria has 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 an uncomplicated hip fracture repair does not require intensive therapy and you 
are unable to participate in intensive therapy. 
 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA genetic testing panel provided on March 2, 2022. 
 
You asked the Plan to pay for the BRCA genetic testing panel. You say that this is an approved test that is 
necessary for patients with cancer to test for BRCA gene mutations. The Plan denied your request. The Plan 
says criteria for this testing are not met. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA gene testing is only covered for enrollees with 
certain types of cancers that presented at certain ages, when they have a sufficient number of relatives that also 
were diagnosed with the same cancer. 
 
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 pay for the BRCA genetic testing panel. Our 
reviewer says that the criteria for this testing were not met. Our physician reviewer found the enrollee has a history breast cancer but has no history of any relatives with breast, ovarian, metastatic prostate or pancreatic 
cancer. The review has determined that the medical records provided did not meet the medical necessity 
requirements for Medicare coverage. 
 
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 BRCA genetic testing panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the BRCA genetic testing panel provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below knee socket insert (L5655). 
 
You asked the Plan to pre-approve a below knee socket insert. You say that the item is necessary. The Plan 
denied your request. The Plan says two of the same sockets have already been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two of the same socket inserts 
(L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual 
prosthesis at the same time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a below knee socket insert have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a below knee socket insert (L5655).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to reconsider their 
denial. 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 July 18, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular 
partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc NP Allograft procedure. 
 
You asked the Plan to pre-approve a Via Disc NP Allograft procedure. 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 effective for services performed on or after 
September 29, 2008, the Centers for Medicare and Medicaid Services has determined that TIPs are not 
reasonable and necessary for the treatment of low back pain. 
 
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 Via Disc NP Allograft procedure. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Via disc allograft is 
experimental. 
 
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 Via Disc NP Allograft procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Via Disc NP Allograft procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs). 
 
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 repeat MBBs 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 the enrollee has chronic low back pain. 
She has not had magnetic resonance imaging (MRI) since 2019. There is no documentation of recent physical 
therapy or home exercise. There is no documentation of follow-up from her prior injections. The criteria for 
coverage are not met and the services are not reasonable or medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat medial branch blocks (MBBs).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the enrollee began taking Lumakras in October 2022. 
You say that this drug is an oral oncolytic that can cause anemia. You also say that the requested drug, Procrit, 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's last dose of 
myelosupressive chemotherapy was greater than 8 weeks ago. The Plan also says that the requested injection is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESA agents are only covered when medically 
necessary and treatment duration for each course of chemotherapy includes the 8 weeks following the final 
dose of myelosuppressive chemotherapy in a chemotherapy regimen. 
 
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 Procrit. Our reviewer says that Procrit 
is not medically necessary for this patient. Our physician reviewer found this patient has a normocytic anemia 
with normal renal function. No information about tests to rule out other sources of anemia are provided such as 
iron studies and B12. Guidelines for Lumakras recommend holding the drug for toxicities or lowering the dose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not require daily skilled nursing and/or skilled therapy services. You are 
medically stable and can receive further rehabilitation services at a lower level of care. 
 
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 SNF care.