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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested drug is recommended due to the 
enrollee's current medical diagnosis. The Plan denied your request. The Plan says the requested drug is not 
medically reasonable or 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 Keytruda. Our reviewer says that the 
requested drug, Keytruda, does not meet the criteria for approval. Our physician reviewer found the FDA has 
not stated that the requested drug regimen 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 regimen in the 
enrollee's clinical situation.  The requested service cannot be recommended as the elements of the coverage 
rules 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of non-compounded foam sclerosant with 
ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and 
monitoring; single incompetent extremity truncal vein (36465). 
 
You asked the Plan to pre-approve injection of non-compounded foam sclerosant with ultrasound compression 
maneuvers to guide dispersion of the injectate. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show the requested treatment 
is for veins that have diameters of less than 4 millimeters in diameter. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater 
than 4 millimeters in diameter and if the patient remains symptomatic after a six-week trial of conservative 
therapy. 
 
   
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 injection of non-compounded foam 
sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found the record indicates that the 
enrollee has varicose veins. The record provided does not document that the veins to be treated are the veins 
are greater than 4 millimeters in diameter or that the enrollee remains symptomatic after a six-week trial of 
conservative therapy following treatment of saphenous reflux. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection of non-compounded foam sclerosant with ultrasound compression 
maneuvers to guide dispersion of the injectate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of non-compounded foam sclerosant with ultrasound compression maneuvers to 
guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent 
extremity truncal vein (36465).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says you do not meet the criteria for SNF placement. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist; however, you do not 
require skilled therapy services on a daily basis. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (SNF) setting. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is at significant risk for a fracture 
and their quality-of-life will would be impacted on intravenous infusions. The Plan denied your request. The 
Plan says that step therapy requirements have not been met. 
 
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 medication. Our reviewer says that 
the request is not medically necessary. Our physician reviewer found that the Plan requires a trial of 
pamidronate and zoledronic acid before they will approve the requested drug. In this case, the enrollee has not 
tried and failed the required drugs. There is no documentation provided indicating 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve denosumab.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown-porcelain/ceramic (D2740) for tooth #5.  
 
You asked the Plan to pre-approve the crown. You say that there are severe distal recurrent caries and a new 
crown is indicated. The Plan denied your request. The Plan says that the request is not medically necessary at 
this time.  
 
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 the crown 
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 the crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found there is recurrent distal marginal caries around 
the crown margin of tooth #5. This cannot be accessed due to the presence of a crown in place. It is medically 
reasonable and necessary to remove the existing crown, remove the caries and place a new crown to provide 
adequate masticatory function and support. The documentation provided meets the criteria for coverage for a 
replacement crown (D2740) for tooth #5. 
 
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 the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown-porcelain/ceramic (D2740) for tooth #5.   
 
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 Zarixo. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that the requested 
drug would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Zarixo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty of lumbar vertebral body L1 (22514). 
 You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of a back brace. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty of lumbar vertebral body L1 (22514).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Minuteman procedure is 
not supported by current peer-reviewed medical literature. Its use has not been shown in controlled studies in a 
Medicare-approved journal to result in long-term health benefits for patients with chronic back pain. The 
services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity revascularization. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
peripheral vascular disease. He has a totally occluded left popliteal artery stent with collateral flow and 
bilaterally occluded anterior tibial arteries with collaterals. The records contain conflicting information on the 
enrollee's smoking status; there is a notation he was never a smoker and another notation that he smokes one 
pack per week. The records do not document significant or disabling symptoms of claudication or limb threatening ischemia. The records document collateral flow around the arterial obstructions. The services are 
not medically necessary based on the submitted documentation. 
 
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 lower extremity revascularization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pneumatic propulsion tire inserts. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted documentation does not 
support that the tire inserts are being requested for a medical purpose. The services are not reasonable or 
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 two pneumatic propulsion tire inserts.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy (IGRT) (codes 77387 x10 and 
G6002 x10). 
 
You asked the Plan to pre-approve IGRT. You say that you want to do image guidance because it is adjacent to 
the first treatment that was done in May, and wanted to treat the left hip iliac. The Plan denied your request. 
The Plan says that this request cannot be approved because picture studies are not supported to guide the 
enrollee's type of treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 IGRT. Our reviewer says that IGRT is 
an accepted standard of care for prior treatment adjacent to the current field. Our physician reviewer found in 
this case, while the intent is clearly palliative, IGRT is being offered in the setting or prior radiotherapy 
adjacent to the current treatment. As increased set-up accuracy is needed in this situation it is plausible that 
IGRT would offer a clinical benefit. Our reviewer also found that while IGRT is not an accepted standard of 
care for routine practice, the prior treatment adjacent to the current field is an exceptional circumstance with 
this enrollee, necessitating the need for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
image-guided radiation therapy (IGRT) (codes 77387 x10 and G6002 x10).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision dental abutments (codes D6191 and 
D6192).  
 
You asked the Plan to pre-approve the semi-precision dental abutments. You did not provide a specific 
argument with your appeal request. The Plan denied your request. The Plan says these dental services are not 
covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
semi-precision dental abutments (codes D6191 and D6192).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested treatment order of pembrolizumab is 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 the medication. Our reviewer says that 
that the requested use of pembrolizumab is not FDA approved for the enrollees diagnosis. Our physician 
reviewer found that the use of pembrolizumab is also not supported by one of the major drug compendia or by 
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) (77014, 
G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the treatment is medically necessary. The Plan denied 
your request. The Plan says Medicare covers tests and treatments which meet but do not exceed the enrollee's 
medical need. More than 20 prostate radiations are not considered necessary for the enrollee's stage of cancer. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found several retrospective studies, and recent randomized studies, have investigated the addition of 
pelvic radiation therapy to the primary site in enrollees with metastatic prostate cancer. The 2023 National 
Comprehensive Cancer Network (NCCN) guidelines recommend external beam radiotherapy to the primary 
site for enrollees with intact prostate and low volume disease. The guidelines specify that High-volume 
disease is differentiated by low-volume disease by visceral metastases and/or 4 or more bone metastases with at 
least one metastasis beyond the pelvis vertebral column. The guidelines emphasize minimizing toxicity from 
radiotherapy and not dose escalating beyond accepted regimens (55 gray (Gy) in 20 fractions or 6 Gy in 6 
fractions). For this case, the enrollee is being offered 44-fractions of IMRT in the setting of a single pelvic bone 
and nodal metastasis. The delivery of >20 fractions of radiation in the metastatic setting seems outside of the 
standard of care based on NCCN guidelines. IMRT is appropriate for this enrollee though there is no plausible 
justification for >20 fractions. The decision is unfavorable for the additional 24 fractions of IMRT. 
 
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 intensity-modulated radiation therapy (IMRT) (77014, G6002, G6015).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 Rytary.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.