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

 
We decided that the Plan does not have to pre-approve Carboplatin and Etoposide. 
 
You asked the Plan to pre-approve Carboplatin and Etoposide. You say that these drugs are medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage for the 
requested drugs have not been met. 
 
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 Carboplatin and Etoposide. Our 
reviewer says that the requested drugs are medically reasonable and necessary. Our physician reviewer found 
that the record indicates that the enrollee has a diagnosis of recurrent metastatic poorly differentiated thyroid 
carcinoma, follicular, Eastern Cooperative Oncology Group performance score of 0 and who has had multiple 
courses of chemotherapy. Additional information was received that states that the enrollee has mixed 
neuroendocrine-non-neuroendocrine neoplasm. 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 Carboplatin and Etoposide have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Carboplatin and Etoposide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET scan is medically necessary to 
evaluate for any recurrence of disease. The Plan denied your request. The Plan says the requested PET scan 
does not meet criteria. 
 
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 
service is not medically necessary. Our physician reviewer found you have had at least 3 PET scans which 
exceeds the Medicare benefit for surveillance PET scans per the guidelines. A cancer antigen 125 (CA125) test 
can be used to follow with CT scan as 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of this device but, there remains almost no randomized blinded clinical studies examining 
long-term clinical outcomes in establishing the value of this device in patient management. 
 
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 there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS HF System (CPT code(s): 33289 and C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe to go home. You say that the 
enrollee still requires assistance for mobility and activities of daily living. The Plan denied your request. The 
Plan says the enrollee can safely receive services in other settings. 
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning  
June 24, 2022, and forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is a danger 
to himself and others and is still inpatient and unable to care for himself on his own. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically necessary. Our physician 
reviewer found that based upon review the records provided it was not expected this enrollee would improve in 
a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats 
of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not 
require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to 
himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee condition or for the purpose 
of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. It appears 
that the services were supervised and evaluated by a physician. This enrollee does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of June 24, 2022 forward 
and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services beginning June 24, 2022, and 
forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says at this point, this device should only be approved for patients enrolled in a clinical trial. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEM is not considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve additional home health skilled nursing visits for the enrollee. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there have been 21 prior visits for similar requests. 
 
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing 
coverage of home care services.  
 
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services 
at issue in this appeal. Therefore, we decided that the Plan has to pre-approve additional home health skilled 
nursing visits for the enrollee.  
 
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 intracept back surgery (CPT code 64628). 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental for back pain. 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-
approve the intracept back surgery (CPT code 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that this procedure fills a treatment gap for those 
patients that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. You state that the enrollee has tried and failed conservative 
treatment without relief. 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 the enrollee's back pain, especially given the 
enrollee's lack of degenerative endplate changes, as well as their facet arthrosis, spinal stenosis, and disc 
bulging. The Plan states the requested procedure is not an accepted standard of medical practice for the 
diagnosis or treatment of back pain and it is considered experimental and 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of 
the procedure for back pain treatment. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (CPT code 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because there is little 
evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's shoulder 
pain. The Plan states it is not an accepted standard of medical practice for the diagnosis or treatment of 
shoulder pain and it is considered experimental and 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Viscosupplentation injections for shoulder pain remain experimental. Also, there is not enough 
conservative measures are documented including steroid injection. 
 
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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); without ultrasound guidance (CPT code 20610).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from June 23, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the continued stay in a skilled nursing level of care exceeds your medical needs. 
 
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 physician reviewer 
found you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from June 23, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this medically necessary. The Plan denied your request. 
The Plan says this use is not supported. 
 
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.  
 
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 Botox. Our reviewer says that the 
requested use of Botox is not supported. Our physician reviewer found Botox is not Food and Drug 
Administration-approved or supported in Medicare-approved compendia for the enrollees diagnosis of 
gastroparesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilflex device 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 
the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex 
superion device placement surgery (CPT code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system (L5910) for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical necessity for the requested system is not met. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested items exceed the patient's medical need as the patient current approved preparatory 
prosthesis is non-alignable and at this time the alignable system is not appropriate for the patient's functional 
level. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an alignable system (L5910) for the enrollee.