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

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor.  
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the CGM will help the enrollee better 
manage diabetes. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
listed in Medicare's Glucose Monitors Local Coverage Determination (LCD) guideline (L33822).  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 sensor. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found coverage criteria require insulin 
use or low blood glucose sugar for CGM coverage. We are not told of any low blood glucose sugar the enrollee 
is having. Although the CGM would help the enrollee who will not check blood glucose sugar due to a fear of 
needles, coverage criteria for the CGM are not met. 
 
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 Dexcom G7 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an iTIND device. 
 
You asked the Plan to pre-approve the iTIND device. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested services are experimental and therefore are not 
covered. 
 
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 iTIND device. Our reviewer says 
that the requested iTIND device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of a temporarily implanted nitinol device (e.g., iTind) is considered 
investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further 
studies are needed to evaluate the durability of iTIND outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate the advantages of second-generation device over the first 
device. The iTIND is not recommended in the most recent AUA Guidelines regarding treatment of BPH. 
Therefore, the reviewer found that the requested iTIND device 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 iTIND device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an iTIND device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that the enrollee indicates that their previous 
provider promised to treat her. The Plan denied your request. The Plan says the enrollee has not trialed a 3-
month conservative treatment regimen. The Plan also says that the enrollee is not symptomatic. 
 The Plan follows Medicare rules. Medicare rules say that surgical treatment and sclerotherapy may be covered 
when the patient is symptomatic. 
 
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 sclerotherapy. Our reviewer says that 
the requested sclerotherapy is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee is asymptomatic. The reviewer found that the enrollee's Health Plan 
does not provide for asymptomatic vein treatments. There is no evidence of medical necessity. Additionally, 
the appropriateness and medical necessity of venous treatments without an assessment of lower extremity 
arterial perfusion cannot be supported. Therefore, the reviewer found that the requested sclerotherapy 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 sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment, includes placement 
(D6057) and an abutment supported crown (D6058). 
 
You asked the Plan to pre-approve dental services. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the requested procedures are not covered by the 
Plan. 
 
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 a 
custom fabricated abutment, includes placement (D6057) and an abutment supported crown (D6058).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving the proper care in the 
current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee continues to receive acute care services and these have not been denied. 
The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH facility. 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the requested drug does not meet the step-
therapy requirements necessary for approval. 
 
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 Euflexxa. Our reviewer says that the 
requested drug does not meet the necessary criteria for approval. Our physician reviewer found that the Plan 
requires that one of the preferred viscosupplemental treatments (Orthovisc or Supartz FX) be trialed first. The 
documentation does not outline contraindications or reasons these medications were not considered or that the 
plan's additional required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Without the support of the documentation, Euflexxa is not approved as the step-therapy criteria have 
not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the care needed in the current 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2023, 
to March 16, 2023.  
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that there is no evidence 
to show that the enrollee required or received home health services during the dates of service in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from February 25, 2023, to March 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer (Iron sucrose) injection. 
 
You asked the Plan to pre-approve Venofer (Iron sucrose) injection. You say that you disagree with the Plan's 
denial. 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 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 Venofer (Iron sucrose) injection. Our 
reviewer says that the documentation does not support that the requested drug is medically reasonable or 
necessary. Our physician reviewer found you have anemia. You are having elective knee surgery. There is no 
indication that you cannot tolerate oral iron therapy. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Venofer (Iron sucrose) injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Venofer (Iron sucrose) injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology care with a specialist outside of your primary 
care physician's referral network. 
 
You asked the Plan to pre-approve neurology care. You say that your hematologist recommended that you be 
seen by a neurologist. The Plan denied your request. The Plan says your primary care physician does not refer 
to this provider and you have instead been referred to another neurology specialist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 neurology care. Our reviewer says that 
you do not meet criteria for treatment with this physician. Our physician reviewer found the Plan's denial is 
medically justified on the basis that it is offering adequate care to meet your needs through the approved 
referral. There is not anything unique about your condition that would make it medically necessary to see the 
physician you have requested. The Plan has shown that their recommended physician meets the standards of 
care required for treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurology care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neurology care with a specialist outside of your primary care physician's referral network.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Urinary Tract Infection (UTI) panel including 17 
pathogens, provided on September 7, 2022. 
 You asked the Plan to pay for the UTI panel. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test panel exceeds what was necessary and 
appropriate for this enrollee. 
 
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 pay for the UTI panel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee presented with symptoms of fatigue. Review of systems notes that there are no 
urinary tract symptoms. There is a discrepancy regarding presence or absence of urinary frequency. The 
presentations and symptoms do not indicate a high likelihood of a urinary tract infection, and therefore 
advanced extended panel testing of Urinary Tract Infection would not have been 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 the UTI panel have not been met. Therefore, we decided that the Plan does not 
have to pay for a Urinary Tract Infection (UTI) panel including 17 pathogens, provided on September 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab. 
 
You asked the Plan to pre-approve Denosumab. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for Denosumab. 
 
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 Denosumab. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee is on androgen deprivation 
therapy with darolutamide and docetaxel for their prostate cancer. Dosing is for prevention of skeletal events 
from osteopenia. However, the enrollee also has skeletal metastases, and this dosing is not standard. The 
enrollee's health plan prefers the use of a bisphosphonate which has not yet been tried and there is no indication 
that this cannot be used. The medication is not reasonable or 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 Denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular artery embolization. 
 
You asked the Plan to pre-approve a genicular artery embolization. You say that the enrollee's condition causes 
significant functional impairment despite appropriate treatment. The Plan denied your request. The Plan says 
this is not medically. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular artery embolization. Our 
reviewer says that the requested genicular artery embolization is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this procedure is experimental for the enrollee's condition. 
Therefore, the reviewer found that the requested genicular artery embolization is not medically reasonable or 
necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a genicular artery embolization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is most 
appropriate for the continuation of medical management, tracheostomy care, and rehabilitation to preserve 
functional independence, mobility, and strength required to return to their prior level of function. The Plan 
denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.