Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee requires skilled stretching 
and bracing to maintain current position for safety. The Plan denied your request. The Plan says 8 additional 
occupational therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has previously been treated with outpatient therapies 
and should be independent with a home exercise program. The enrollee has no recent injury or a decline in 
function. The additional therapy services are not appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional occupational therapy visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a step therapy exception cannot be granted. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of intravenous pamidronate or zoledronic acid before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drugs. There is no indication 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xgeva.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight home health aide (HHA) visits. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that while 
home health services were approved, the services of a home health aide are not shown to be required to assist in 
the treatment of an acute illness or injury. As such, the requested HHA services are not medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve eight home health aide (HHA) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #27. 
 
You asked the Plan to pre-approve a crown. You say that this crown is medically necessary The Plan denied 
your request. The Plan says a crown is not needed to fix the tooth. 
 
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 a crown 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 a crown. Our reviewer says that  Our 
physician reviewer found the documentation provided does not meet the criteria for coverage for a crown 
restoration (D2751) for tooth #27. 
 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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) for tooth #27.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection (J0585). 
 
You asked the Plan to pre-approve a Botox injection. You say that you would like the enrollee to receive Botox 
injections for pelvic pain. The Plan denied your request. The Plan says this request for Botox is not reasonable 
or necessary at this time. 
 
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 a Botox injection. Our reviewer says 
that a Botox injection is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the requested use of Botox is not FDA-approved for the enrollee's diagnosis of chronic pelvic pain and 
myofascial pelvic pain syndrome. The use of Botox for treatment of chronic pelvic pain and myofascial pelvic 
pain syndrome is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS)-approved medical journal. Our reviewer also found that the 
use is not indicated, supported or recommended in any of the compendia. 
 
 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 Botox injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Botox injection (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), lateral spot pad 
with vinyl cover (K0108), fusion display and programmer (K0108), and pulse mechanical switch (K0108). 
 You asked the Plan to pre-approve a power seat elevation system, lateral spot pad with vinyl cover, fusion 
display and programmer, and pulse mechanical switch. You say that the medical documentation supports the 
need of the custom medical equipment being requested. The Plan denied your request. The Plan says the seat 
lift does not serve a medical purpose and cannot be covered. The Plan says the approved controller comes with 
all hardware, switches and other parts needed for it to work properly, and these parts cannot be requested 
separately. The Plan also says the approved cushions come with covers, and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature. 
 
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 fusion display and programmer and 
pulse mechanical switch. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has very advanced multiple 
sclerosis (MS) but functions with their current chair. There is no evidence the accessories are medically 
necessary as they are beyond what the enrollee currently requires. Our reviewer found that the power seat 
elevation is considered not medically necessary, and the enrollee requires a mechanical lift transfer. Our 
physician reviewer also found that it is not reasonable to offer the power seat to improve function. 
 
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 power seat elevation system, lateral spot pad with vinyl cover, fusion display 
and programmer, and pulse mechanical switch have not been met. The record shows that the cushions that were 
approved for the enrollee have covers. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system (E2300), lateral spot pad with vinyl cover (K0108), fusion display and 
programmer (K0108), and pulse mechanical switch (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pocket coil mattress to be purchased from a vendor 
that does not accept Medicare. 
 
You asked the Plan to pre-approve a pocket coil mattress. You say that you feel that you have more than 
provided the prescriptions and needs for your request. The Plan denied your request. The Plan says the pocket 
coil mattress for which coverage is being requested does not fit the Medicare definition of durable medical 
equipment (DME), and is not a covered benefit of Medicare. The Plan also says the requested vendor does not 
accept any insurance payments, and is not a Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that to receive payment for covered Medicare items or services, a 
provider or supplier must be enrolled in the Medicare program. 
 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 pocket coil mattress to be purchased from a vendor that 
does not accept Medicare.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
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 positron emission tomography (PET) 
scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria 
for approval are not met. 
 
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 positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee lives in an assisted living facility and is dependent for mobility and uses a Hoyer lift for transfers. The 
documentation indicates that the enrollee is at his baseline level of function and there is no indication for a need 
for physical/occupational therapies or his ability to participate in therapies. He receives assistance with daily 
activities. The enrollee is noted to be receiving outpatient care for his medical issues and his catheter is being 
changed monthly on an outpatient basis with urology. The enrollee does not require home health nursing care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the 
enrollee's treatment for diabetic retinopathy with macular edema. The Plan denied your request. The Plan says 
the requested drug does not meet step therapy criteria. 
 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has diabetic retinopathy with macular edema. The requested 
medication is a new start. 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea (J0178).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
September 1, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you disagree with 
the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $800 deductible which applies to cardiac rehabilitation services.  
 
The item or service you asked the Plan to waive the copayment for falls within the cardiac rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $800 deductible which applies to cardiac rehabilitation services. At the time of your service, you did not 
meet your deductible, so you are being asked to pay $213.60 towards your $800 deductible. This cost sharing is 
a contractual obligation that had not been met at the time cardiac rehabilitation services was received on 
September 1, 2022. Therefore, we decided that the Plan does not have to waive the copayment for cardiac 
rehabilitation services provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation. 
 
You asked the Plan to pre-approve a genicular nerve ablation. You say that a genicular nerve ablation is 
medically necessary. The Plan denied your request. The Plan says the requested genicular nerve ablation 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 genicular nerve ablation. Our 
reviewer says that the requested genicular nerve ablation is not considered medically reasonable and necessary 
in this case. Our physician reviewer found genicular nerve ablation is considered an experimental/ 
investigational treatment and it is the subject of ongoing clinical trials. 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 a genicular nerve ablation. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transperineal placement of biodegradable material, peri-
prostatic, single or multiple injection(s), including image guidance, when performed (55874). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is only indicated when radiation is the treatment planned. The records do not show 
that the enrollee is having radiation therapy for treatment of his prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met.  Therefore, we decided that the Plan does not have to pre-approve transperineal placement of biodegradable 
material, peri-prostatic, single or multiple injection(s), including image guidance, when performed (55874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical research study services. 
 You asked the Plan to pre-approve clinical research study services. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve clinical research study services as part of a clinical trial. The 
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan 
does not have to pre-approve clinical research study services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary in this case. Our physician reviewer found that the provided 
records do not document verification from the enrollee's treating provider that all other reversible causes of 
anemia have been ruled out. The prior authorization document provided specifically indicates that all other 
reversible causes of anemia have not been ruled out. Based on the medical records provided there is no 
documentation that Aranesp meets all Medicare criteria for safe and effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.