Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliances (E0667 and E0656).
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 require rehabilitation to regain independence 
after surgery. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 chemotherapy drugs, Tecentriq and MVASI. 
 
You asked the Plan to pre-approve Tecentriq and MVASI. You say that you would like to continue the 
combined use of MVASI and Tecentriq to treat the enrollee's liver cell carcinoma. The Plan denied your 
request. The Plan says the service requested fails to meet the definition of reasonable and 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 Tecentriq and MVASI. Our reviewer 
says that the enrollee's condition does not meet criteria to use the requested chemotherapy drugs, Tecentriq and 
MVASI. Our physician reviewer found the enrollee's disease has progressed and the use of the requested drugs 
are not approved or supported by the FDA, major drug compendia, or clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq and MVASI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chemotherapy drugs, Tecentriq and MVASI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this CGM would help with monitoring the enrollees 
glucose levels. The Plan denied your request. The Plan says the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantable loop recorders are only covered for 
certain indications. 
 
 
 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 implantable loop recorder. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a history of atrial fibrillation. There is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an implantable cardiac monitor (ICM). In summary, there is insufficient documentation to 
support the medical necessity for insertion of an ICM in this enrollees 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral enteral formula. 
 
You asked the Plan to pre-approve oral enteral formula. You say that the enrollee is having to use all of their 
benefits for this item. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the enteral formula requested is for oral 
use. This is specifically not covered. Based on this information, we decided that Medicare rules for coverage of 
oral enteral formula have not been met. Therefore, we decided that the Plan does not have to pre-approve oral 
enteral formula.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim NEO device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device is considered 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 you have symptoms thought due to chronic systolic heart failure (CHF) despite medical 
management, in setting of severely reduced left ventricular function. Baroreflex stimulation devices have been 
considered potential alternative treatments for resistant hypertension and heart failure. There remains an 
absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value 
of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim NEO device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit and ECG. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services were not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit and an ECG provided on January 4, 
2023, by an OON provider.
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 the services are medically necessary based on the 
enrollee's condition and current functional deficits as well as multiple comorbidities. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve medial branch blocks at two levels. We decided that the Plan does 
not have to pre-approve a medial branch block at the third level.  
 
You asked the Plan to pre-approve the medial branch blocks. The Plan says that the medial branch blocks are 
not 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the LCD limits the number of 
levels to be treated to two levels. Therefore, only two levels are medially 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 the medial branch blocks at three levels have not been met. Therefore, we 
decided that the Plan has to approve medical branch blocks at two levels and does not have to pre-approved the 
third level.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total laparoscopic hysterectomy (58571, 58661).  
 
You asked the Plan to pre-approve the surgical service. You say that you would like to appeal this denial. The 
Plan denied your request. The Plan says this procedure 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 the surgical service. Our reviewer says 
that the requested laparoscopic hysterectomy is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation provided does not include the result of genetic testing or the 
failure of medical management of your condition. The reviewer found that the documentation provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service 
at this time. Therefore, the reviewer found that this service 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a total laparoscopic hysterectomy (58571, 58661).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home 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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic hypoxic respiratory failure from chronic obstructive pulmonary disease. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-
assured pressure support (AVAPS) capability to provide the ordered settings. Failure of such a device has not 
been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Clarifix, posterior nasal nerve cryoablation (30117, 
30469). 
 
You asked the Plan to pre-approve Clarifix procedure. You say that the enrollee has a long-standing history of 
nasal obstruction issues. You also say that there is no other option available to durably treat the enrollee's 
condition. The Plan denied your request. The Plan says Clarifix 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 Clarifix procedure. Our reviewer says 
that the requested Clarifix procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has chronic rhinitis and nasal congestion. There 
is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the reviewer found that the requested Clarifix procedure 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 Clarifix procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Clarifix, posterior nasal nerve cryoablation (30117, 30469).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis bone stimulator. 
 
You asked the Plan to pre-approve an osteogenesis bone stimulator. You say that please see the new medical 
records and recent x-ray t review and provide authorization for bone growth stimulator to service the enrollee. 
The Plan denied your request. The Plan says there is no documentation of recent imaging which shows the 
fracture is not healing. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The records show 
that the enrollee had a right ankle fracture. The records also include an x-ray from November 17, 2022, 
computed tomography from December 29, 2022, and office visit notes from May 22, 2023, that does not have 
any imaging results. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased.  Therefore, we decided that the Plan does not have to pre-
approve an osteogenesis bone stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion (22869, 22870, C1821).  
 
You asked the Plan to pre-approve Vertiflex Superion. You say that this treatment is considered safe and 
effective. The Plan denied your request. The Plan says Vertiflex Superion device does not meet accepted 
standards of medical practice  
 
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 Vertiflex Superion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex Superion (22869, 22870, C1821).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with temozolomide (J8700). 
 
You asked the Plan to pre-approve temozolomide. You say that temozolomide is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that temozolomide has been prescribed for an off-label, 
not medically accepted use. 
 
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 temozolomide. Our reviewer says that 
temozolomide is medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of temozolomide is not FDA-approved for the enrollees diagnosis. However, the is use 
supported by one of the major drug compendia. The documentation supports that the requested drug is safe and 
effective and otherwise 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 temozolomide have been met. Therefore, we decided that the Plan has to pre-
approve treatment with temozolomide (J8700).  
 
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.