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

 
We decided that the Plan does not have to pre-approve Retacrit Solution, Tecentriq, and Avastin. 
 
You asked the Plan to pre-approve Retacrit Solution, Tecentriq, and Avastin. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested drugs are 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 Retacrit Solution, Tecentriq, and 
Avastin. Our reviewer says that the documentation does not support that Our physician reviewer found the 
enrollee has a diagnosis of hepatocellular carcinoma and is receiving chemotherapy. The documentation 
indicates that the enrollee had a hemoglobin of less than 10 mg/dl in August and has received the requested 
drug. The record does not indicate a current hemoglobin. The records provided are insufficient to establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested drugs. Therefore, the 
enrollee does not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit Solution, Tecentriq, and Avastin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Retacrit Solution, Tecentriq, and Avastin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device, bi-level pressure capability, 
without backup rate feature, used with noninvasive interface (E0470) and a humidifier, heated, used with 
positive airway pressure device (E0562). 
 
You asked the Plan to pre-approve a respiratory assist device and a humidifier. You say that the BIPAP 
machine you have fell apart, the hose started sucking water from the well and pieces of the well went into hose. 
The Plan denied your request. The Plan says you were previously approved for a BIPAP machine. DME 
supplies are limited to equipment and devices which do not duplicate the 
function of another piece of equipment or device covered by the Plan and 
are appropriate for use in the home. 
 
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. The records show you were approved for a BIPAP machine on June 
24, 2022. The Medicare rules confirm that you would be covered for the requested device if at least five years 
has passed since you last received the same or similar device and/or your item needs to be replaced due to 
irreparable damage. Based on this information, we decided that Medicare rules for coverage of a respiratory 
assist device and a humidifier have not been met. Therefore, we decided that the Plan does not have to pre-
approve a respiratory assist device, bi-level pressure capability, without backup rate feature, used with 
noninvasive interface (E0470) and a humidifier, heated, used with positive airway pressure device (E0562).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pluvicto, a prescription drug. 
 
You asked the Plan to pre-approve a prescription drug. You say that you feel taxane chemotherapy is 
contraindicated in this enrollee's given risk of progressive neuropathy which could render him non-ambulatory. 
Given risks associated with taxane therapy, best treatment option for this enrollee is Pluvicto. The Plan denied 
your request. The Plan says the information provided by the doctor did not meet the requirements for covering 
this drug. Pluvicto is subject to prior authorization. For the Plan to cover this drug, the enrollee must have been 
previously treated with taxane-based chemotherapy (such as docetaxel or cabazitaxel). 
 
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 a prescription drug. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found provided records do not document 
that the enrollee has had prior treatment with taxane-based therapy. Without prior taxane-based therapy, 
Pluvicto is not indicated for metastatic castration-resistant prostate cancer as defined by the Medicare-approved 
major drug 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 prescription drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pluvicto, a prescription drug.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve armodafinil. 
 
You asked the Plan to pre-approve armodafinil. You say that the requested drug is medically necessary for the 
enrollee. 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 armodafinil.  
 
Benefits for armodafinil 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 pre-approve the RhinAer procedure. 
 
You asked the Plan to pre-approve the RhinAer procedure. You say that the RhinAer procedure is medically 
necessary. The Plan denied your request. The Plan says the RhinAer procedure is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the RhinAer procedure. Our reviewer 
says that the requested the RhinAer procedure is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in this case, the record indicates that the enrollee has vasomotor 
rhinitis that is improved with ipratropium administration. There is insufficient literature to support the safety 
and efficacy of the requested service for the enrollee's specific conditions. The record provided does not 
establish the medical necessity and reasonableness as defined by Medicare rules of the requested service. The 
elements of the coverage criteria are not satisfied.  
 
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 RhinAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the RhinAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT Peripheral Nerve Stimulation (PNS) 
System (CPT code 64555). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says this treatment is still being studied to see if this treatment is as good or better than 
standard treatment for chronic pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/ investigational. There are other evidence based interventions 
available for this enrollee. The request is deemed 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SPRINT Peripheral Nerve Stimulation (PNS) System (CPT code 64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 You asked the Plan to pre-approve the compression stockings. 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 compression stockings described by code A6530 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, Group 3 standard, single power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) 22 NF sealed 
lead acid battery, (E2361) manual swingaway (E1028) power seating system, tilt only (E1002) positioning 
wheelchair back cushion, (E2620) electronic connection between wheelchair controller and two or more power 
seating system motors, (E2311) complete leg rest system. E1012) any type of cushioned headrest (E0955) Skin 
protection and positioning wheelchair seat cushion (E2607). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the enrollee meets the 
requirements for a group 3 base and meets all of Medicares requirements The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for the requested group 3 power wheelchair with power tilt. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is not at high risk for skin breakdown, has intact skin and 
does not use a ventilator or intermittent catheterization which are criteria which must be met for a group 3 
wheelchair with power lift 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 the power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve power wheelchair, Group 3 standard, single power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0856) 22 NF sealed lead acid 
battery, (E2361) manual swingaway (E1028) power seating system, tilt only (E1002) positioning wheelchair 
back cushion, (E2620) electronic connection between wheelchair controller and two or more power seating 
system motors, (E2311) complete leg rest system. E1012) any type of cushioned headrest (E0955) Skin 
protection and positioning wheelchair seat cushion (E2607).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous 
basivertebral nerve ablation at L4, in this case, 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that the requested power mobility device 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power mobility device. Our reviewer 
says that the enrollee does not meet criteria for the requested power mobility device. Our physician reviewer 
found the enrollee does not have a mobility deficit which prevents him from performing mobility associated 
activities of daily living. 
 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 mobility device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power mobility device.
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 you had knee surgery and heart attacks. You say 
that your day to day mobility is extremely limited for you and there is evidence that your mobility is failing. 
The Plan denied your request. The Plan says based on your current needs you can safely receive the services 
you need in other settings. For example, at home with supervision and home health services, or in an assisted 
living facility with home health services.  
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 there is no recommendation for frequency of skilled nursing specified. Evaluating 
therapists recommend daily skilled therapy in an SNF but listed the therapy goals have been met, thus there is 
no documentation to show that you would require daily skilled services in an SNF. You do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found that you do 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there is no documentation of the duration and degree of pain relief from the last epidural steroid injection. 
Therefore, the criteria are not met and the request is deemed 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from April 27, 2022, to May 26, 2022. 
 
You asked the Plan to pay for home health services. You say that a Notice of Admission (NOA) was submitted 
and accepted. The Plan denied your request. The Plan says that the NOA was submitted on an incorrect type of 
bill. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say Notice of Admissions (NOAs) are submitted using type of bill 032A. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Although the Plan states that the NOA was submitted on an incorrect type of 
bill, the NOA in the file is on a type of bill 032A. The Plan has not provided information to show that it is 
otherwise invalid. Therefore, we decided that the Plan has to pay for home health services provided from April 
27, 2022, to May 26, 2022.  
 
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 pre-approve percutaneous implantation of neurostimulator electrode 
array on the peripheral nerve. 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array on the 
peripheral nerve. You say that percutaneous implantation of neurostimulator electrode array on the peripheral 
nerve is medically necessary. The Plan denied your request. The Plan says percutaneous implantation of 
neurostimulator electrode array on the peripheral nerve 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 percutaneous implantation of 
neurostimulator electrode array on the peripheral nerve. Our reviewer says that the requested percutaneous 
implantation of neurostimulator electrode array on the peripheral nerve is not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the use of peripheral nerve stimulation in low 
back pain is not supported by adequate clinical evidence at this point. It is considered experimental/ 
investigational. Therefore, the request is deemed 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 percutaneous implantation of neurostimulator electrode array on the peripheral 
nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of neurostimulator electrode array on the peripheral nerve.