Persius/hicric huggingface dataset:
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 you are still having an extremely hard time moving 
on your own and performing daily activates. You were advised you are at risk of your oxygen levels dropping, 
causing you to become unconscious. Physical, Occupational, and Speech therapy are crucial for your treatment 
plan The Plan denied your request. The Plan says IRF care is not medically necessary, and you can be managed 
at a lower level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
smoke inhalation and respiratory failure, but your medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cisplatin with docetaxel and bevacizumab combination 
therapy. 
 
You asked the Plan to pre-approve the requested chemotherapy regimen. You say that this treatment should be 
allowed due to progression on other therapies and allergies to carboplatin. The Plan denied your request. The 
Plan says there is no support for this treatment in the compendia. 
 
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 the requested chemotherapy regimen. 
Our reviewer says that the requested chemotherapy regimen is not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a female with metastatic ovarian cancer. The requested treatment is not 
FDA-approved for the enrollee's diagnosis. In addition, the use of this regimen is not supported by the major 
drug compendia or clinical research in a Medicare-approved medical journal.  
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 chemotherapy regimen have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cisplatin with docetaxel and bevacizumab combination therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan 
denied your request. The Plan says that the medical records submitted did not support that this imaging is 
medically necessary as the member is not receiving active treatment and the cancer is in remission. 
 
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 PET scan. Our reviewer says that a 
PET scan is medically necessary. Our physician reviewer found that while it is true that the enrollee is not 
currently receiving therapy, she has had evidence via PE previously of recurrence and she now has weight loss 
and shortness of breath. A PET/CT is reasonable based on these past events. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET scan.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the off-label use of this 
drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on 
available information. 
 
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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer 
found that the Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan provided by an out-of-network provider on 
August 25, 2021. 
 
You asked the Plan to pay for the duplex scan. You say that the attached medical records support this claim for 
reprocessing for payment. The Plan denied your request. The Plan says the non-urgent services are not 
authorized because the provider is a non-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the duplex scan provided by an out-of-network 
provider on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal decompression and fusion surgery. 
 
You asked the Plan to pre-approve the requested spinal surgery. You say that the enrollee's findings of right 
foot drop shows that surgery is necessary at this time. The Plan denied your request. The Plan says it is not 
clear from the documentation that surgery is the best option at this time. A trial of physical therapy is 
appropriate at this time. 
 
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 spinal surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the records provided have no documentation of a trial of conservative measures. 
Since the foot drop is noted to be mild, a trial of physical therapy is needed prior to surgery. 
 
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 spinal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal decompression and fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM).. You say that you cannot stick your 
fingers because you get sick and nauseous when you see blood. The Plan denied your request. The Plan says 
the enrollee does not meet the required coverage criteria as he is not currently insulin treated with 3 or more 
daily injections of insulin or a Medicare covered continuous subcutaneous insulin infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor (CGM). have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose 
monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left radiofrequency ablation (RFA) (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that her last procedure that was on the left 
side was done on 5/15/2019 with 90% relief for 6 months. You see no reason that this procedure should be 
denied. The Plan denied your request. The Plan says the records do not show that the enrollee does not meet the 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollees most recent RFA at the requested levels was more than 
two years ago, in May 2019.  The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left radiofrequency ablation (RFA) (64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L5-S1 Lumbar Epidural Steroid Injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that you would like reconsideration because the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 
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 ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the use of fluoroscopy (a picture study using x-rays that show real time images) or Computed 
Tomography (CT), detailed picture study, is supported for needle guidance.   The enrollee's records do not show this type of guidance is planned for the epidural steroid injection. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the L5-S1 Lumbar Epidural Steroid Injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Spinal Simplicity interspinous-
interlaminar fusion device. 
 
You asked the Plan to pre-approve the Spinal Simplicity device placement. You say that this should be allowed 
to assist with the enrollee's condition. The Plan denied your request. The Plan says this is not proven effective 
as a standalone treatment. 
 
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 Spinal Simplicity device placement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found interspinous devices remain experimental. More research is needed to 
support medical necessity.  
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 Spinal Simplicity device placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of the Spinal Simplicity interspinous-interlaminar 
fusion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar fusion. 
 
You asked the Plan to pre-approve the lumbar fusion. You say that you would like reconsideration because the 
requested procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage. 
 
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 lumbar fusion. 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 lumbar instability. 
 
 
 
 
 
 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 lumbar fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the lumbar fusion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with 
neurogenic claudication. The record indicates that the enrollee has multi-level lumbar disease with thecal sac 
compression on an imaging study done in May 2021. The record does not state that the enrollee is not a 
candidate for operative intervention at no more than two levels. There are insufficient recent records to 
demonstrate whether the coverage criteria are satisfied at this time.    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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation (E2300). 
 
You asked the Plan to pre-approve the power seat elevation. You say that you would like reconsideration 
because the power seat elevation is medically necessary. The Plan denied your request. The Plan says the 
power seat elevation does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 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 the power seat elevation (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on 
November 23, 2021. 
 
You asked the Plan to pay more for the periodontal maintenance. You say that the Plan is supposed to provide 
payment for one dental cleaning per year after the patient deductible is satisfied. You also say that the Plan's 
payment of $4.50 is not in accordance with the stated benefits. The Plan denied your request. The Plan says this 
claim processed and paid correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay based 
on the allowed amount of the service. The allowed amount of the service after the $50 deductible and $50 
copayment is $9. This means that the claim processed correctly. Therefore, we decided that the Plan does not 
have to pay more for the periodontal maintenance (D4910) provided on November 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee will not gain her mobility back 
without a SNF stay and should not be home due to immobility. The Plan denied your request. The Plan says the 
enrollee does not require daily skilled nursing or skilled therapy in a SNF setting. 
  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 services. Our reviewer says that 
there are no identifiable skilled nursing service needs. Our physician reviewer found that there are identifiable 
skilled therapy service needs, but the enrollee does not require skilled therapy services on a daily basis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
November 29, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you believe your dentist 
should be compensated for this x-ray. The Plan denied your request. The Plan says your $1,500 benefit 
maximum had been met while processing this claim. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the November 29, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
additional intraoral periapical x-ray (D0230) provided on November 29, 2021.