Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product (VIA disc therapy) (0627T). 
 
You asked the Plan to pre-approve VIA disc therapy. You say that the enrollee would benefit from this 
procedure. The Plan denied your request. The Plan says the requested injection of allograft into the 
intervertebral disc for the treatment of degenerative disc disease is considered experimental and 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 VIA disc therapy. 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 an experimental procedure. Therefore, the reviewer found that VIA 
disc therapy is 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 VIA disc therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product (VIA disc 
therapy) (0627T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine foot care benefit exception for six additional 
visits per year. 
 
You asked the Plan to pre-approve a routine foot care benefit exception for six additional visits per year. You 
say that you need your toenails trimmed and it has to be done more often than four times per year. You say you 
have fungus and ingrown toenails, and you cannot cut your toenails by yourself. The Plan denied your request. 
The Plan says the benefit only allows up to four podiatry visits per year. 
 
The Plan contract covers routine podiatry visits, up to four supplemental routine visits every year. 
 
We looked at the file and the Plans rules. The Plan covers up to four supplemental routine podiatry visits every 
year. Therefore, we decided that the Plan does not have to pre-approve a routine foot care benefit exception for 
six additional visits per year.
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 an 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 in this case. Our physician reviewer 
found that the enrollee does not have radicular symptoms or neurogenic claudication. The enrollee does not 
meet the LCD 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One injections. 
 
You asked the Plan to pre-approve the Synvisc One. You say that this should be approved as requested. The 
Plan denied your request. The Plan says the preferred drugs can be safely tried. 
 
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 Synvisc One. Our reviewer says that 
the requested drug is not medically reasonable and necessary based on step therapy requirements. Our 
physician reviewer found based on the medical records provided, there is no indication that the enrollee has 
tried and failed the required drugs, Gel One or Euflexxa. There is also no indication that the Plan's required 
drug(s) 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 Synvisc One have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc One injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred step therapy drugs. 
 
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 Feraheme. Our physician reviewer 
found that the enrollee has iron deficiency anemia with intolerance to or inadequate response to oral iron 
replacement. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. There 
is no indication that the enrollee has tried and failed the required drugs. There is no indication that the Plan's 
required drugs would likely be less effective 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lexiscan to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a Lexiscan. You say that this test was recommended to you by your doctor, 
and you do not understand why it was denied. The Plan denied your request. The Plan says a Lexiscan to be 
performed at an OON location is not medically necessary for your condition. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 Lexiscan. Our physician reviewer found there is no evidence of urgency 
in the test to be done at the requested OON location and it can safely be done in a network location nearby. 
 
 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 Lexiscan have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve a Lexiscan. Therefore, we decided that the Plan does 
not have to pre-approve a Lexiscan to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home mechanical ventilator (E0466) set in 
intelligent volume-assured pressure support (iVAPS) mode with automatic expiratory positive airway pressure 
(Auto-EPAP). 
 
You asked the Plan to pre-approve a ventilator. You say that you were not aware that prior authorization was 
needed for this item. You say that the enrollee has tried and failed the continuous positive airway pressure 
(CPAP) on bilevel positive airway pressure (BiPAP). The Plan denied your request. The Plan says the 
requested ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that a 
ventilator is not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee has severe chronic obstructive pulmonary disease (COPD), mild obstructive sleep apnea, intolerant of 
continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The reviewer found 
that a venous blood gas was done in November 2022, but there is no arterial blood gas (ABG), done while 
stable, to document chronic carbon dioxide retention. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. Given that the enrollee is intolerant to the mask interface with CPAP 
and BiPAP, it seems unlikely a ventilator with a noninvasive interface would be able to be used. Therefore, the 
reviewer found that the a ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home mechanical ventilator (E0466) set in intelligent volume-assured pressure 
support (iVAPS) mode with automatic expiratory positive airway pressure (Auto-EPAP).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says a genicular nerve block is experimental. 
 
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 block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but 
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to 
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the genicular nerve block is 
considered experimental/investigational in nature. The requested  genicular nerve block 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer - porcelain/ceramic for resin bonded fixed 
prosthesis tooth #'s 6 and 8 (D6548), and pontic - porcelain fused to predominantly base metal tooth #7 
(D6241). 
 
You asked the Plan to pre-approve codes D6548 and D6241. You say that a removable bridge seems bulky and 
excessive. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 codes D6548 
and D6241 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 codes D6548 and D6241. Our reviewer 
says that the dental services are not medically necessary.  Our physician reviewer found the requested bridge from tooth #6-8 is not currently indicated due to the 
periodontal condition of teeth, #7 and #8. Tooth #7 needs removal but also has significant bone loss, as does 
#8. If tooth #8 is to be used for a bridge abutment there must be a periodontal treatment to stabilize the obvious 
bone loss in the area. Given the current periodontal status of the teeth, particularly tooth #8, a bridge is not 
necessary. The plan provides the placement of a fixed prosthetic appliance will only be considered for those 
exceptional cases where there is documented physical or neurological disorder that would prelude placement of 
a removable prosthesis. In this instance there has been no indication of any physical or neurological disorder in 
the record. 
 
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 codes D6548 and D6241 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a retainer - porcelain/ceramic for resin bonded fixed prosthesis tooth #'s 6 
and 8 (D6548), and pontic - porcelain fused to predominantly base metal tooth #7 (D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466) set in pressure 
support (PS). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has a qualifying diagnosis. You also 
say that bi-level positive airway pressure (BiPAP) and BiPAP spontaneous/timed therapy (ST) are insufficient 
for the enrollee. The Plan denied your request. The Plan says the requested ventilator is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that a 
ventilator is not medically necessary. Our physician reviewer found the provided documentation indicates the enrollee has chronic obstructive pulmonary disease (COPD) and was hospitalized a few months ago with 
pneumonia and sepsis. The reviewer found that an arterial blood gas (ABG) while acutely ill showed mild 
carbon dioxide (CO2) retention. There is no ABG done while stable to confirm chronic CO2 retention.  
Therefore, the reviewer found that the requested ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator (E0466) set in pressure support (PS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L3-L5 lumbar decompression and fusion. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you are requesting a fast appeal due to 
the enrollee's continued symptoms. The Plan denied your request. The Plan says the medical policy 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 the surgical 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 documentation of recent and adequate physical therapy. There is no severe 
stenosis on magnetic resonance imaging (MRI) at L3-4 and no correlation with physical exam findings 
showing neurologic deficit. Surgery is not needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the L3-L5 lumbar decompression and fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ZIP interspinous fusion procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is not suited for a pedicle 
screw fixation. The Plan denied your request. The Plan says the service is considered experimental and 
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 requested services. Our physician 
reviewer found that the Aurora Zip spine procedure is experimental. More research is needed to show its safety 
and efficacy. Therefore, the request is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ZIP interspinous fusion procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient services. You say that your symptoms are progressing. The Plan 
denied your request. The Plan says an inpatient admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient services. Our physician 
reviewer found that you have suspected normal pressure hydrocephalus (NPH). A high-volume lumbar 
puncture (HVLP) has been approved by the Plan. There is no specific clinical rationale for the requested inpatient admission. The record does not show that your necessary hospital care will span two midnights. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve acute inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression Garment 
System (K1033, K1024). 
 
You asked the Plan to pre-approve the Koya Dayspring Active Compression Garment System. You say that 
this device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Koya Dayspring Active 
Compression Garment System. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found although records from the device 
manufacturer argue medical necessity of the requested device, records from the enrollee's actual treating 
provider do not clarify why the requested device is the most appropriate treatment for the enrollee's 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 the Koya Dayspring Active Compression Garment System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression 
Garment System (K1033, K1024).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have chronic obstructive pulmonary 
disease (COPD) and asthma, and do not understand why you were denied. The Plan denied your request. The 
Plan says based on the information submitted there is no documentation that you meet all 3 criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).