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

 
We decided that the Plan does not have to pre-approve the ReActiv8 nerve stimulator device coded as 64555, 
64590, and C1778. 
 
You asked the Plan to pre-approve the nerve stimulator device. You say that it is your position that the denial 
for this procedure is unwarranted and unsupported based on the enrollee's current medical status. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ReActiv8 device in the setting of 
low back pain have not been demonstrated in the peer-reviewed literature. 
 
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 nerve stimulator device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the ReActive device 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 nerve stimulator device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the ReActiv8 nerve stimulator device coded as 64555, 64590, and C1778.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (64555). 
 
You asked the Plan to pre-approve the Sprint Peripheral Nerve Stimulator. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 Sprint Peripheral Nerve Stimulator. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this device is considered experimental. More research is needed to show 
safety and efficacy. 
 
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 Sprint Peripheral Nerve Stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Sprint Peripheral Nerve Stimulator (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home prothrombin/international normalized ratio 
(PT/INR) monitoring. 
 
You asked the Plan to pre-approve the monitoring. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requirements have not been 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 monitoring. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at issue is the appropriateness of home prothrombin/international normalized ratio 
(PT/INR) monitoring in this patient who became incapacitated during 2022 and can longer carry out the testing 
herself and relies on a caregiver to carry out the test. However, Medicare guidelines specify that the patient 
must be able to use the machine independently. In summary, the documentation does not support the 
appropriateness of home prothrombin/international normalized ratio (PT/INR) monitoring in this patient. 
 
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 monitoring have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home prothrombin/international normalized ratio (PT/INR) monitoring.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular nerve block (64624). 
 
You asked the Plan to pre-approve the Genicular nerve block. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been 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 Genicular nerve block. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this service is considered investigational. More research is needed to show safety 
and efficacy. 
 
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 Genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Genicular nerve block (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
 
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 Dupixent.  
 Benefits for Dupixent 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint RFA (radiofrequency ablation). 
 
You asked the Plan to pre-approve thermal facet joint RFA. 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 initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 thermal facet joint RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found it has been more than two 
years since the previous radiofrequency ablation. The diagnostic procedures must be repeated and only one set 
of diagnostic medial branch blocks have been performed. Therefore, at this time, the request for repeat RFA 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 thermal facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal facet joint RFA (radiofrequency ablation).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH can provide continuity of 
care. The Plan denied your request. The Plan says the enrollee is receiving the necessary care in the current 
hospital and there is no need to transfer to the LTACH at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the 
same vessel (37226). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the records do not show that you completed a structured or home-based 
exercise program or attempted medication to help your symptoms. 
 
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 surgical service. Our reviewer says 
that the requested lower extremity revascularization is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the evidence does not confirm that treatment with maximal guideline-
directed medical therapy, such as a program of structured exercise, medications such as a statin and cilostazol, 
and smoking cessation have been carried out. Therefore, the reviewer found that the requested service is not 
medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), 
unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel (37226).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E2311, E2313, E2377. We decided that the Plan does not have to 
pre-approve E2300.  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, E2300).. 
You say that this is medically necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve E2311, E2313, E2377.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered if 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 for E2311, E2313, E2377. Our reviewer says that the 
enrollee has very limited strength in the upper extremities to manage multiple power drive controls. The 
request meets criteria for medical necessity. 
 
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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve E2311, E2313, E2377.  
 
We also decided that the Plan does not have to pre-approve E2300. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is not covered 
because it is primarily medical in nature. 
 
E2300 is not considered primarily medical in nature. Items that are not considered medical in nature are not 
covered. Based on this information, we decided that Medicare rules for coverage of E2300 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve E2300. 
 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 group 3 standard power wheelchair (PWC) with 
multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) 
and accessories (E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2604). 
 
You asked the Plan to pre-approve a group 3 PWC and accessories. You say that the enrollee needs this PWC. 
The Plan denied your request. The Plan says the enrollee does not have a qualifying condition for a group 3 
PWC. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition;  
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair (PWC) with multiple power option, sling/solid seat/back, patient weight 
capacity up to and including 300 pounds (K0861) and accessories (E0955, E1007, E1012, E1028, E2311, 
E2313, E2361, E2377, E2604).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 the home ventilator. Our physician 
reviewer found there is no documentation this has been tried and shown to fail as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with 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 the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Stelara (J3358). 
 
You asked the Plan to pre-approve Stelara. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Stelara. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Humira or Skyrizi before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Stelara (J3358).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that  Medication given by injection (parenterally) is not 
covered if standard medical practice indicates that the administration of the medication by mouth (orally) is 
effective and is an accepted or preferred method of administration. 
 
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 this 
drug is not medically necessary. Our physician reviewer found the record provided does not document that 
there is a medical reason that precludes oral iron administration. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) (J1459). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no literature to support that IVIG is indicated to treat Norovirus. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that intravenous 
immune globulin (IVIG) is considered not medically necessary.  This patient is a lung transplant recipient in 
2018, on chronic immunosuppression.  The patient developed diarrhea in February and tested positive for 
norovirus. The diarrhea and positivity for norovirus have persisted, despite treatment with nitoxonade. IVIG 
has not been shown to be effective in the treatment of norovirus infection in immunocompromised patients. There is evidence of lack of benefit.  There have been case reports of using oral immunoglobulin, but evidence 
of benefit is anecdotal and there are no controlled clinical trials. This patient's immunoglobulin G (IgG) level is 
only mildly reduced.  
 
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 intravenous immune globulin (IVIG) (J1459).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe supports to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve custom shoe supports to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom shoe supports to be provided by an out-of-network (OON) provider.