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

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day sensor. 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14-day sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Functional Electrical Stimulation (FES).  
You asked the Plan to pre-approve FES. 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 NMES/FES for walking will be covered in SCI 
patients under certain circumstances. 
 
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 FES. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found unfortunately; the use of FES is not 
covered when there is brain injury. The request does not meet the NCD criteria and therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FES have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Functional Electrical Stimulation (FES).
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 admission to IRF care is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The enrollees needs can be met at a lower level of care, such as a skilled nursing facility 
(SNF). 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Mvasi. 
 
You asked the Plan to pre-approve Mvasi. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Mvasi. Our reviewer says that the 
services are medically necessary. Our physician reviewer found Bevacizumab (Mvasi) is supported by the 
medical literature for use in vulvar cancer (treated similar to cervical cancer). Use is supported as a single agent 
and as combination therapy with carboplatin and paclitaxel. In the elderly paclitaxel is often dropped for 
expected toxicities. The service is reasonable and 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 Mvasi have been met. Therefore, we decided that the Plan has to pre-approve 
Mvasi.  
 
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 computed tomography (CT) scan of the brain. 
 
You asked the Plan to pre-approve a CT 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 must follow Medicare rules. Medicare rules say that CT 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 CT scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found while a pacemaker is not 
specifically mentioned in the submitted records there is a statement that "the patient is due for a battery 
change."  If indeed a pacemaker is present, an MRI of the brain would be contraindicated by the device and a 
CT would be the procedure of choice. As the submitted records only imply a pacer is present, but no statement 
specifies one is in place, a contraindication to an MRI and the necessity of a CT scan is not able to be 
established. 
 
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 CT scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the brain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc or Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc or Synvisc-One. 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 the patient's medical record should contain 
documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate 
(Hyalgan, Supartz or Visco-3TM, EuflexxaTM, MonoviscTM, GelSyn-3TM, GenVisc 850, Durolane, 
TriViscTM, SynojoyntTM, TriluronTM), hylan G-F 20 (Synvisc, Synvisc-One TM), hyaluronic acid (Gel-One), 
high molecular weight hyaluronan (Orthovisc) and high molecular weight viscoelastic hyaluronan 
(Hymovis). 
 
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 Synvisc or Synvisc-One. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the use of a viscosupplement in this enrollee would be off-label. The request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc or Synvisc-One have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc or Synvisc-One (J7325).
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 the enrollee would recover much faster with the 
continued SNF stay. You say the enrollee is mentally and physically too weak to be independent. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for a continued SNF stay. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6240, D6750) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic and retainer crown (D6240, D6750)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGM supply allowance provided on August 21, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that the COVID-19 waiver for health care 
provider was extended until the end of the year. The Plan denied your request. The Plan says that the date of 
service on the claim does not match the delivery/shipping date or the date the label was created. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record also shows that the date of service on the 
claim does not match the delivery/shipping date or the date the label was created. Therefore, we decided that 
the Plan does not have to pay for the CGM supply allowance provided on August 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation system 
(E0483). 
 
You asked the Plan to pre-approve the high frequency chest wall oscillation system. You say that you request 
reconsideration of approval for high frequency chest wall oscillation system services for the enrollee due to 
chronic obstructive pulmonary disease. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested the high frequency chest wall oscillation system does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise 
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the 
high frequency chest wall oscillation system (E0483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of carotid sinus Baroreflex activation 
device, total system (0266T). 
 
You asked the Plan to pre-approve the procedure. You say that please consider this request for a 
predetermination and preauthorization of benefits to treat the enrollee. The Plan denied your request. The Plan 
says there is not enough medical evidence to show that this procedure has better long-term health outcomes for 
people. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the implantation of carotid sinus Baroreflex activation device, total system (0266T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a the CGM. You say that the services should be covered as you disagree 
with the denial The Plan denied your request. The Plan says the services denied correctly as they do not meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM)
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 27, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the enrollee was not enrolled in hospice 
for this date of service. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 22, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital care 
provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dupixent syringe (J3590). 
 
You asked the Plan to pre-approve the Dupixent syringe. You say that you would like this medication to be 
approved because the enrollee cannot afford the cost for it. The Plan denied your request. The Plan says the 
Dupixent syringe is a self-administered drug. 
 
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 a Dupixent syringe (J3590).  
 
  Benefits for the Dupixent syringe 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. 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 lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record provided 
does not indicate the presence of a red flag signs or symptoms or any abnormal neurological findings. The 
record does not indicate failure of a trial of conservative therapy. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Precision QID Test strip. 
 You asked the Plan to pre-approve the Precision QID Test strip. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the requested item is not on the Plan's preferred brand list. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Precision QID Test strip have not been met. Specifically, there is no evidence that the enrollee 
requires this item over a plan preferred item. Therefore, we decided that the Plan does not have to pre-approve 
the Precision QID Test strip.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve intense pulsed light therapy (CPT code 17999). 
 
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 that this service will not repair a recent accidental injury or improve the 
function of an abnormal body part. 
 
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 service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is medically necessary to treat rosacea. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve intense pulsed light therapy (CPT code 17999).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of fluoride (D1208). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
application of fluoride is not covered by the Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
application of fluoride (D1208).