Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth tooth extractions. 
 
You asked the Plan to pre-approve these services. You say that your dental issues are worsening. The Plan 
denied your request. The Plan says the 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. The extractions are not covered by your medical benefit because they 
are not being performed to prepare the jaw for radiation treatment. Therefore, we decided that the Plan does not 
have to pre-approve full mouth tooth extractions.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that you have regressed not being able to 
continue therapy.  The Plan denied your request. The Plan says you can continue your home exercise program 
at this time. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. You have had instruction in a home exercise program. The requested additional therapy 
sessions do not require ongoing skilled professional therapist supervision. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7. 
 
You asked the Plan to pre-approve a Dexcom G7. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that there is no evidence provided indicating that the two 
preferred products have been ineffective. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a continuous glucose monitor. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiation therapy. 
 
You asked the Plan to pre-approve the radiation therapy. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the request is considered investigational and is otherwise not medically 
necessary and reasonable. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the effectiveness of radiation therapy for the treatment of plantar fasciitis has not 
been sufficiently assessed in randomized placebo-controlled trials. In addition, it is not known whether there is 
increased risk of carcinogenesis in this setting following radiation therapy.  
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 radiation therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the radiation therapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam treatment. 
 
You asked the Plan to pre-approve proton beam treatment. You say that this procedure is medically necessary 
for the enrollee. The Plan denied your request. The Plan says that that all criteria have not been met for 
Medicare coverage. 
 
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 proton beam treatment. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is a plan comparison that shows that the proton plan meets the accepted 
constraints from NRG GU007 (a randomized phase II trial of niraparib with standard combination androgen 
deprivation therapy) while the Intensity-modulated radiation therapy (IMRT) plan does not. The records do not 
describe exceptional circumstances for why this might be the case, and the prescribed dose of greater than 70 
Greys is arguably higher than one might typically use (though within the National Comprehensive Cancer 
Network (NCCN) guideline recommendations). It is also not clear that a better optimized IMRT plan would 
result in an acceptable plan. Nevertheless, a plan comparison showing an unacceptable IMRT plan suggests 
that proton therapy would be within accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam treatment have been met. Therefore, we decided that the Plan has 
to pre-approve proton beam treatment.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub wall rail (E0241). 
 
You asked the Plan to pre-approve a bathtub wall rail. You say that the wall rail is very much needed for your 
safety when getting into and out of the shower. The Plan denied your request. The Plan says this is considered 
self-help and hygiene equipment and is not primarily medical and nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a bathtub wall rail (E0241).
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for an IRF admission. 
 
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.  
Specifically, the enrollee is not shown to be able to currently tolerate 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardiacMEMs device.  
 
You asked the Plan to pre-approve CardiacMEMs device. You say that the requested CardiacMEMs device is 
medically necessary. The Plan denied your request. The Plan says the requested CardiacMEMs device is 
experimental and 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 CardiacMEMs device. Our reviewer 
says that the requested CardiacMEMs device is not considered medically reasonable and necessary. Our 
physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope (1). Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device (2). In addition, published expert 
opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there 
remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing 
the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not 
be considered medically appropriate and necessary 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 CardiacMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardiacMEMs device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve the medication. 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 Ondansetron tablets.   
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heated humidified high flow therapy system. 
 
You asked the Plan to pre-approve a heated humidified high flow therapy system. You say that the requested 
item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
the requested item have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heated humidified high flow therapy system have not been met. Specifically, the case record 
shows that the requested equipment is for use with purchased oxygen equipment. Therefore, we decided that 
the Plan does not have to pre-approve a heated humidified high flow therapy system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a repeat epidural 
steroid injection 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 injection. Our reviewer says that 
that the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has a 
history of chronic low back pain due to lumbar spinal stenosis with radiculopathy. While the enrollee has been 
treated with medications, a home exercise program, and has undergone multiple epidural steroid injections, the 
caudal epidural steroid injection performed on April 19, 2023, provided no relief in pain. Therefore, the 
enrollee does not meet the LCD coverage criteria. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this item is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the continuous glucose monitor have been met. No clinical records were provided to show that the requested equipment is medically necessary. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath transfer chair (E0247). 
 
You asked the Plan to pre-approve a bath transfer chair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
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 a bath transfer chair (E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease (COPD) in the setting of lung cancer. The records show he 
was successfully treated with bi-level positive airway pressure (BiPAP) therapy in the hospital. The failure of a 
BiPAP machine is not documented. The criteria for coverage are not met and the requested ventilator 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 01, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on November 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 19, 2023, and billed with codes 87150, 87798, 87481, 87653, 87640, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel provided on January 19, 2023, and billed with codes 87150, 87798, 87481, 87653, 87640, and 
87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says CardioMEMS should only be approved for patients in a clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes to establish the value of CardioMEMS in patient 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three home physical therapy visits and three home 
occupational therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you can 
improve function with repetitive exercise. You do not require unique input from a skilled therapist to continue 
the exercises. 
 
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 pre-approve three home physical therapy visits and three home occupational therapy visits.