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

 
We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by 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 Synthroid tablets.  
 
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa. 
 
You asked the Plan to pre-approve Pradaxa. You say that the enrollee has intolerance of Eliquis, and is 
tolerating Pradaxa. The Plan denied your request. The Plan says Pradaxa is a self-administered drug, and does 
not fall under Part B coverage. 
 
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 Pradaxa.  
 
  Benefits for Pradaxa 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF is recommended as the next level of care. The 
Plan denied your request. The Plan says the denial of IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's condition is chronic and intensive rehabilitation services are not required. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Globus Signify Crunch bioactive glass allograft for 
spinal surgery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says published studies do not demonstrate any long-term health outcome advantage with the 
use of bioactive glass as an alternative to standard bony allografts. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is planning to undergo anterior cervical discectomy and fusion at C5-7 with 
hardware. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate the efficacy of the requested allograft. The gold standard for cervical spine fusions remains an 
autograft. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested Globus Signify Crunch bioactive glass allograft for spinal surgery, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Globus Signify Crunch bioactive glass allograft for spinal surgery.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on January 6, 2022, billed with code 99202. 
 
You asked the Plan to pay for the office visit. You say that an electronic claim was submitted on January 16, 
2022, with no response. A paper claim was then submitted on May 20, but now both claims have been denied 
as duplicate. You feel that payment should be made for one unit of 99202. The Plan denied your request. The 
Plan says that two units of 99202 were billed, and only one is allowed. As such, this was denied correctly. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not supported the denial rationale in this case. The Plan indicates 
that only one unit can be paid of code 99202 and that two units were billed. However, the Plan has not provided 
any evidence in the file to show that any units of this code were paid. The appeal documentation shows that 
two claims were submitted with 1 unit, and both were denied due to exceeding the medically unlikely edit 
(MUE). Without evidence that at least one unit has been paid for this date of service, we find that the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the office visit provided on 
January 6, 2022, billed with code 99202.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Signatera testing (81479). 
 
You asked the Plan to pre-approve Signatera testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because 
the records show that the enrollee does not have colon or bladder cancer and has not received immune-
checkpoint inhibitor therapy. 
 
The Plan follows Medicare rules. Medicare rules say that Signatera Tests are covered for the diagnosis of 
disease progression, recurrence, or relapse for colon cancer; bladder cancer; or monitoring of response to 
immune-checkpoint inhibitor therapy for any solid tumor. 
 
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 Signatera testing. Our reviewer says 
that this service does not meet criteria for coverage. Our physician reviewer found that based on the medical 
records provided there is no documentation of a diagnosis of disease progression, recurrence, or relapse for 
colon cancer, bladder cancer or monitoring of response to immune-checkpoint inhibitor therapy for a solid 
tumor, as required by the Local Coverage Article. Thus, the testing at issue in this case does not meet all 
Medicare criteria for medically reasonable and necessary 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 Signatera testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Signatera testing (81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. 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 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 RFA to the SI joint. 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 and investigational due to the wide variation in 
effectiveness reported in the literature. 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in your clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract between 
the dialysis facility and the laboratory regarding payment. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy called Proton Beam Therapy (77387, 
77470, 77520, 77522, 77523, 77525, G6002). 
 
 
 
 You asked the Plan to pre-approve radiation therapy. You say that the enrollee will be treated with high total 
dose of Proton with 34 GY, two fractions per day (BID), for 5 days (total of 10 fractions). Given her age, 
complexity of disease and grade 3 and 4 toxicities that conventional radiation therapy produces in her case, 
PBT is the only modality that can accurately and safely treat her disease without exceeding QUANTEC dose 
thresholds to her heart, lung, and contralateral breast. Given the urgency and clinical complexity of her life-
threatening cancer diagnosis, the Plan must approve this request immediately and without further delay. The 
Plan denied your request. The Plan says the enrollee has a history of early-stage breast cancer. Proton beam 
therapy is not generally accepted for breast cancer, especially early stage. Proton beam therapy is not 
recommended for breast cancer in any national guidelines, including NCCN. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the planning records provided (only a proton plan and no plan comparison) there is 
no demonstration with quantifiable dosimetric measures that proton therapy is needed. The appeal letter 
advocates for the need of proton therapy in generic/boilerplate format. However, IMRT is a standard technique 
which allows for relative sparing of normal tissues and would be the accepted standard of care for enrollees 
undergoing APBI with external beam radiation. Routine use of proton therapy for breast cancer is not an 
accepted standard of care. While proton therapy can be used (and is often used for select enrollees with unique 
anatomic considerations) the case file does not provide a plausible rationale for the need of proton therapy over 
conventional radiation and/or IMRT in this 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 radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy called Proton Beam Therapy (77387, 77470, 77520, 77522, 77523, 
77525, G6002).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex, Darzalex Faspro, and Velcade in combination 
with Decadron. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of multiple 
myeloma. The requested regimen is prescribed as first line treatment. The Food and Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The requested drug combination is not reasonable or medically necessary or safe and 
effective 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darzalex, Darzalex Faspro, and Velcade in combination with Decadron.
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. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not qualify for SSBCI. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
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 SSBCI. Our reviewer says that you do 
not meet criteria for SSBCI. Our physician reviewer found you have a history of morbid obesity status post 
gastric bypass, systemic lupus erythematosus (SLE), transient ischemic attack (TIA), Sjogren's syndrome, 
Bipolar disorder, Schizoaffective disorder, anxiety, depression, and asthma. You have been evaluated for a 
microcytic anemia and have been diagnosed with microcytic anemia secondary to iron deficiency anemia 
secondary to malabsorption. The documentation does not support that you require intensive care management, 
are at high risk for hospitalization, and have a qualifying comorbid and medically complex condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI 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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that image-guided superficial 
radiation therapy is medically necessary for this enrollee. Further, the non-ionizing ultrasound imaging 
component utilized with superficial radiation performed, will allow you to track the progress of treatment in 
real time and will allow any adjustments, if needed, daily and throughout the delivery of radiation. The Plan 
denied your request. The Plan says the request does not meet the Medicare or health plan coverage criteria. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for 
which the target lesion can be seen on the skin to assist in daily set up. Certainly, using ultrasound on a daily 
basis is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or IGRT for a 
technology for which need has not been established by published data or supported by consensus guidelines 
(many of which recommend against treatment with these devices in general) is not necessary. The decision is 
unfavorable as billing for daily IGRT which would not be furnished in accordance with accepted standards of 
medical practice". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic prostate 
cancer. The Food and Drug Administration (FDA) has not stated that the requested drug formulation is 
indicated for the enrollee's condition. The Medicare-approved  drug compendia do not contain a supportive 
citation for the use of the requested drug formulation in the enrollee's clinical situation. Prolia is therefore not 
reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee is not able to tolerate oral iron. You say 
that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
requested drug is not medically necessary. 
 
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 Injectafer. Our reviewer says that the 
requested use of Injectafer is not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. Therefore, the reviewer found that the requested drug is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).