Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ventricular assist device supplies to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON ventricular assist device supplies. You say that it is imperative that 
all components of the enrollee's implanted device function properly for the enrollee to be monitored and to 
remain stable. You say that the requested supplies are detrimental for the enrollee's condition and have 
previously been deemed medically necessary and supported by clinical documentation. The Plan denied your 
request. The Plan says the provider requesting the supplies for the heart pump is not in the network. The Plan 
says that the items needed can be obtained from an in-network provider. 
 
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items from an OON provider. Therefore, we decided that the Plan does not have to pre-
approve ventricular assist device supplies to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the cause of the symptoms is unclear. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there is a wide 
range of differential diagnoses in this case. It's not clear from the records that the enrollee meets the diagnostic 
criteria for either Alzheimer's disease or fronto-temporal dementia, let alone both. Other factors such as 
psychiatric conditions and long-term medication could be contributing as well. 
 
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 positron emission tomography (PET) of the brain.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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. 
 
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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve injections. You say that you disagree with the denial and submitted 
additional information. The Plan denied your request. The Plan says it has not been 3 months since the previous 
injection. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the coverage criteria, a repeat ESI, when the first injection directly and 
significantly provided improvement of the condition being treated, may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale for at least three (3) months. If an enrollee 
fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, 
level and/or medication, if appropriate, with the rationale and medical necessity for the second ESI documented 
in the medical record. In this case, the most recent TFESI was performed on 10/19/2022. The review has 
determined that the requested injection is not medically necessary for the enrollee. The enrollee does not meet 
LCD criteria for coverage of the requested 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 5, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve an increased dose of infliximab. 
 
You asked the Plan to pre-approve an increased dose of infliximab. You say that the increase to the enrollee's 
infliximab dosage is medically necessary and supported by data. You say that this is the most conservative 
course of action for the enrollee. You say that changing this enrollee to an alternative medication prior to a trial 
of dose escalation could put the enrollee at risk to develop anti-drug antibodies and may limit future use of 
infliximab. The Plan denied your request. The Plan says that the requested amount of the dug requested 
exceeds the amount or dose indicated by accepted standards of medical practice. 
 
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 an increased dose of infliximab. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the appellant has 
abdominal pain, elevated white blood cell count, and imaging evidence of terminal ileal wall thickening in the 
setting of Crohn's disease. Granted, the enrollee also has a history of recurrent pancreatitis and required a 
steroid taper course earlier in 2022.  The enrollee's infliximab drug level remains inadequate despite doubling 
his infliximab dose in May of 2022. The proposed infliximab dose of 10mg/kg every 6 weeks is at the high-end 
of standard of care but meets approval criteria as safe and effective and otherwise reasonable and necessary for 
his 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 an increased dose of infliximab have been met. Therefore, we decided that the 
Plan has to pre-approve an increased dose of infliximab.  
 
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 pay for procedure code 99024 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 99024. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99024 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor V Leiden (F5) genetic testing. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing for the F5 gene for all risk factors, 
signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, is non-covered except for 
pregnant patients. 
 
We looked at the file and Medicare rules. The services at issue are F5 genetic testing. This testing is non-
covered by Medicare except for pregnant patients. Therefore, we decided that the Plan does not have to pre-
approve Factor V Leiden (F5) genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) for the upper right and upper left quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) for the upper right and upper left quadrants. You say that this service code is also used for deep 
cleaning, which is the service that was being provided on July 26, 2022. The Plan denied your request. The 
Plan says there is no attachment loss that allows for the planing of roots. The Plan also says that the provided 
radiographs don't support the presence of root exposure. 
 
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. The Plan covers periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) for the upper right and upper left quadrants 
when the services are medically necessary and reasonable.   
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 periodontal scaling and root planing - 
four or more teeth per quadrant (D4341) for the upper right and upper left quadrants. Our reviewer says that the 
requested dental services are not medically reasonable and necessary. Our physician reviewer found despite 
pocket readings in excess of 3 millimeters (mm) in more than four areas, there is no noted bone loss around 
four or more teeth in the upper right and upper left quadrants to be considered under code D4341. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing - four or more teeth per quadrant (D4341) 
for the upper right and upper left quadrants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341) for the 
upper right and upper left quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637). 
 
You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that enrollee has 
imbalance, incoordination, and poor motor function. He needs the assistive devices. An enrollee with this 
problem should be given every opportunity to strengthen their muscles and bones, improve their function, and 
regain their independence. The Plan denied your request. The Plan says the requested device does not serve a 
medical purpose and is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum pump and a Rush Rampage EVQ8 foot for a 
leg prosthesis. 
 You asked the Plan to pre-approve a vacuum pump and a Rush Rampage EVQ8 foot. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 a vacuum pump and a Rush Rampage 
EVQ8 foot. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that the Rush Rampage EVQ8 foot is not medically necessary and 
exceeds the enrollee's needs. The available physician documentation does not support that the enrollee's 
functional level requires a K3 foot. The vacuum pump exceeds the enrollee's medical needs and is not proven 
superior to a standard socket. The literature reviewed indicates that further research is needed, with clinical 
trials that recruit larger sample sizes and report long-term outcome data for the requested elevated vacuum 
suspension system. 
 
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 vacuum pump and a Rush Rampage EVQ8 foot have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a vacuum pump and a Rush Rampage EVQ8 foot for a 
leg prosthesis.
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 considered a high fall risk and has a 
continued need for daily medical management/monitoring or comorbid conditions.  The Plan denied your 
request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are 
requesting do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for urinary tract infection and a COVID-19 infection. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee had a dual 
energy x-ray absorptiometry (DEXA) scan that revealed that she has osteopenia and not osteoporosis. The Plan 
also says that Prolia is only covered for a diagnosis of osteoporosis. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our reviewer 
also found that the elements of the coverage criteria are not satisfied, and 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. 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 ultrasound diagnostic procedures 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 a TTE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found if it is confirmed that an echocardiogram 
has been performed already, there is no need to repeat the study. Clinical guidelines do not support repeating a 
TTE with no intervening change in clinical status or physical findings. In summary, there is no supportive 
evidence for the medical necessity of repeat TTE in this enrollee's 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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fosfomycin Tromethamine 3 GM Powder Pack. 
 
You asked the Plan to pre-approve Fosfomycin Tromethamine. You say that the requested drug is medically 
necessary for the enrollee. The Plan denied your request. The Plan 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 Fosfomycin Tromethamine 
3 GM Powder Pack.