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

 
We decided that the Plan has to pre-approve Inclisiran (Leqvio). 
 
You asked the Plan to pre-approve Inclisiran (Leqvio). You say that the requested Inclisiran (Leqvio) is 
medically necessary.  The Plan denied your request. The Plan says that the requested Inclisiran (Leqvio) 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 Inclisiran (Leqvio). Our reviewer says 
that the requested Inclisiran (Leqvio) is medically necessary. Our physician reviewer found based on the 
Medicare-approved major drug compendia there is documentation that supports that the Leqvio at issue in this 
case meets all Medicare criteria. Inclisiran is indicated as an adjunct to diet and maximally tolerated statin 
therapy to treat adults with clinical atherosclerotic cardiovascular disease (ASCVD) who require additional 
lowering of LDL-C. Provided records in this case document the enrollee with atherosclerotic heart disease has 
an LDL-C level of 87 from November 2022 while on maximally tolerated statin therapy. The Food and Drug 
Administration-approved indication for Leqvio does not require trial and failure of ezetimibe as the health plan 
is requiring in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Inclisiran (Leqvio) have been met. Therefore, we decided that the Plan has to 
pre-approve Inclisiran (Leqvio).  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve oncology (cutaneous melanoma), mRNA, gene expression 
profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping) (81529). 
 
You asked the Plan to pre-approve oncology (cutaneous melanoma), mRNA, gene expression profiling by real-
time RT-PCR of 31 genes (28 content and 3 housekeeping). You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are covered under certain circumstances. 
 
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 oncology (cutaneous melanoma), 
mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping). Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets all the 
coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oncology (cutaneous melanoma), mRNA, gene expression profiling by real-
time RT-PCR of 31 genes (28 content and 3 housekeeping) have been met. Therefore, we decided that the Plan 
has to pre-approve oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 
31 genes (28 content and 3 housekeeping) (81529).  
 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 MyoPro arm brace. 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that this device has been embraced by 
clinicians nation-wide and recommended in American Heart Associate (AHA) guidelines for stroke 
rehabilitation as the only available treatment for individuals with moderate to severe upper limb paresis.  The 
Plan denied your request. The Plan says this brace is experimental and cannot be approved. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested MyoPro orthosis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested MyoPro orthosis is not considered medically reasonable and necessary 
in this case. Our physician reviewer found he MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for the enrollees condition or in widespread use for the enrollees condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for the enrollee. Therefore, the reviewer found that the orthosis 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro arm brace.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure addresses a gap in 
treatment algorithm for those suffering from chronic low back pain. You say that the enrollee has tried and 
failed conservative treatment without relief. You also say that the science supporting the safety and 
effectiveness of the procedure is robust. The Plan denied your request. The Plan says the requested 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not have imaging showing modic changes 
without facet degenerative joint disease or foraminal stenosis. The reviewer also found that the documentation 
does not clearly show the cause of the enrollee's back pain. Therefore, the reviewer found that the requested 
procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651) and 
appliance (E0667). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the enrollee does not need these items. Our physician reviewer found the provided 
records in this case do not document the persistence of chronic and severe lymphedema. Records do not 
document, with detailed measurements, a four-week trial of conservative therapy demonstrating failed response 
to regular and compliant use of an appropriate compression bandage system or compression garment to provide 
adequate graduated compression, regular exercise and limb elevation. Records do not include any assessment 
performed by the treating practitioner or any other licensed/certified medical professional directly involved in the patient's lymphedema treatment who has been certified as having no financial relationship with the 
equipment supplier providing the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651) and 
appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scleral contact lenses provided on August 1, 2022. 
 You asked the Plan to pay for scleral contact lenses. You say that these lenses were covered under your 
previous insurance plans. The Plan denied your request. The Plan says contact lenses are only covered 
following cataract surgery. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam every 12 months. 
 
We looked at the file and the Plan's rules. The Plans vision benefit does not cover contact lenses. Based on this 
information, we decided that the Plan's rules for coverage of scleral contact lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for scleral contact lenses provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiology second-opinion consultation to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve second-opinion consultation. You say that your physician keeps telling you 
that you are fine, but you are not. The Plan denied your request. The Plan says this provider is out-of-network 
with the Plan and you can be treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a cardiology second-opinion consultation to be provided by an out-of-network (OON) provider.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission based on medical necessity. The Plan denied your 
request. The Plan says the request for 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that this will affect your day-to-day life. You say 
that if you do not get physical therapy, you are afraid you will end up in a wheelchair. You say that physical 
therapy is medically necessary.  The Plan denied your request. The Plan says the records sent do not support 
the request for treatment.   
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 physical therapy. 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 additional requested therapy is not generally accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. 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 the patient's current condition or to prevent or slow further deterioration. The patient has 
had extensive therapy for this condition and has had instruction in a home exercise program. The requested 
additional formal therapy sessions 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1843). 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any knee instability, recent injury, or surgery. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records show that the knee is stable, as the pain has been present since 2018/2019. There has not 
been any recent injury or surgery to the knee. 
 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1843).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary capsules. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing this denial. 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 capsules.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy procedure provided on January 26, 2023, 
billed with diagnosis codes D12.4 and K63.5. 
 
You asked the Plan to pay for the colonoscopy as billed. You say that the services were medically necessary 
and should be paid. The Plan denied your request. The Plan says this was billed with two diagnosis that cannot 
be reported together. 
 The Plan must follow Medicare rules. Medicare rules say that provider must comply with the ICD-10-CM 
coding guidelines. These guidelines indicate that some diagnosis codes have Excludes1 notes which indicate 
other diagnosis codes they cannot be reported with.  
 
We looked at the file and Medicare rules. Diagnosis code D12.4 has an Excludes1 note which indicates it 
cannot be billed with K63.5. Based on this information, we decided that Medicare rules for coverage of the 
colonoscopy as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
colonoscopy procedure provided on January 26, 2023, billed with diagnosis codes D12.4 and K63.5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator. 
 
You asked the Plan to pre-approve a tremor stimulator. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the requested item 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 a tremor stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient evidence in the literature that this device would be effective 
for the enrollee. The requested Cala Trio device is not the standard of care for the enrollee's tremor according 
to current guidelines. 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 tremor stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb tremor stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87551, 87798, 87481) provided on February 3, 
2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was 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 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 lab testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found suspected toenail fungal infections do not typically require confirmation testing as this is generally 
diagnosed based on history and physical.  
 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 lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (87551, 87798, 87481) provided on February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for emergency care services provided upon a ship outside of United States 
waters on April 29, 2022. 
 You asked the Plan to pay for emergency care services. You say that you hurt your head when you had a fall on 
a cruise ship. The Plan denied your request. The Plan says that the claim processed correctly per the benefit 
allowance. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are only covered under limited, specified circumstances. The Plan has a 
worldwide coverage benefit that goes beyond Medicares rules. For that reason, the Plans rules apply to this 
case. 
 
We looked at the file and Medicare rules. These services do not fall within Medicares rules for coverage 
because the ship upon which the services took place departed a United States port more than 6 hours prior to 
the time of service. Therefore, the services are not considered to have taken place in United States territorial 
waters. However, these services do fall within the Plans worldwide emergency care benefit. You were treated 
by the ships hospital after suffering an injury to the head. A prudent layperson with an average knowledge of 
medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy 
to their health. Additionally, the Plans claim that the maximum benefit was paid is incorrect as the worldwide 
coverage benefit is up to $25,000 per calendar year, but the Plan only remitted $366.22 to you. Based on this 
information, we decided that the Plans rules for coverage of emergency care services have been met. 
Therefore, we decided that the Plan has to pay for emergency care services provided upon a ship outside of 
United States waters on April 29, 2022.  
 
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.