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

 
We decided that the Plan does not have to pre-approve CCTA. 
 
You asked the Plan to pre-approve a CCTA. You say that you are appealing with supporting medical records. 
The Plan denied your request. The Plan says that the requested CCTA is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CCTA. Our reviewer says that the 
CCTA is not medically necessary. Our physician reviewer found that the provided records in this case do not 
document the need for a cardiac evaluation for chest pain syndrome. The provided records also do not 
document the need for an assessment of suspected congenital anomalies of coronary circulation. 
 
 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 CCTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CCTA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA DISC NP allograft procedure. 
 
You asked the Plan to pre-approve the VIA DISC NP allograft procedure. You say that the VIA DISC NP disc 
tissue allograft is medically necessary for the patient. It is intended to replace degenerative tissue loss in 
patients suffering from chronic low back pain. The Plan denied your request. The Plan says the VIA DISC NP 
allograft procedure is not medically necessary because evidence is lacking. Published studies do not 
demonstrate any long-term health outcome advantage with the use of VIA DISC NP as an alternative to 
standard treatments. 
 
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 VIA DISC NP allograft procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the VIA DISC NP allograft procedure is considered 
experimental/investigational 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 VIA DISC NP allograft procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the VIA DISC NP allograft procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the patient is in constant paid and can 
only walk a few steps. The Plan denied your request. The Plan says the Intracept procedure is not medically 
necessary for this patient. There patient's Magnetic Resonance Imaging (MRI) indicates that the patient has 
neurocompression and a bulging disc at the proposed treatment level. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient's MRI shoes other pathology with disc herniation.  Because the cause of 
the patient's pain is not clear, this 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 the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271 x6 cycles). 
 
You asked the Plan to pre-approve Keytruda. 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 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 Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found per major drug compenida, pembrolizumab 
monotherapy for recurrent head and neck cancer guidelines are to continue until disease progression, 
unacceptable toxicity, or (in patients without disease progression) for up to 24 months. She had a p ulmonary 
thromboendarterectomy (PTE) February 24, 2023, that showed no evidence of disease. The service 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271 x6 cycles).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended sleep study. 
 
You asked the Plan to pre-approve an attended sleep study. You say that you have provided medical records to 
support authorization for this service. The Plan denied your request. The Plan says an attended sleep study is 
not medically necessary as the enrollee is not having any changes in sleep apnea symptoms. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered when medically 
necessary for certain conditions. 
 
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 an attended sleep study. Our reviewer 
says that an attended sleep study is not medically necessary. Our physician reviewer found this patient has a 
known diagnosis of obstructive sleep apnea; and has been using bilevel positive airway pressure (BiPAP) 
successfully for many years. Her current device is more than 10 years old and is no longer transmitting 
data. There are no new symptoms of obstructive sleep apnea, and the patient is using and benefiting from the 
device. The Epworth score is 4.  Medicare does not require a sleep study in order to obtain a replacement 
device, when the device is more than 5 years old and no longer fully functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attended sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the wig purchased on December 30, 
2022. 
 
You asked the Plan to provide reimbursement for the wig. You say that you were told that you could use any 
provider and request reimbursement. You feel this should be paid. The Plan denied your request. The Plan says 
this is only covered for hair loss due to treatment for cancer. The records do not show a history of cancer or 
hair loss related to treatment for cancer. 
 Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan provides an additional benefit for wigs only when the hair loss is caused by 
treatment for cancer. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. The records do not indicate hair loss due to cancer treatment, so this is also 
not covered under the supplemental benefit. Therefore, we decided that the Plan does not have to provide 
reimbursement for the wig purchased on December 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab. 
 
You asked the Plan to pre-approve bevacizumab. You say that the enrollee's condition is not being controlled 
well on Lynparza alone. You say that the requested drug should be added to the enrollee's regimen to better 
control the disease. You also say that the enrollee did not have the opportunity to use this drug with the first 
line of chemotherapy due to being enrolled in a clinical trial. The Plan denied your request. The Plan says the 
requested drug is not indicated for the enrollee's condition. The Plan also says the enrollee has not tried and 
failed the preferred drugs. 
 
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 bevacizumab. Our reviewer says that 
bevacizumab is not reasonable and necessary in this case. Our physician reviewer found the use of 
bevacizumab for the enrollees diagnosis is not FDA-approved in combination with olaparib for recurrence and 
also not based on elevation in circulating tumor cells. The use of bevacizumab for the enrollee's condition is not 
supported or recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bevacizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bevacizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation of varicose veins. 
 
You asked the Plan to pre-approve the requested vein ablation. You say that this treatment is necessary. The 
Plan denied your request. The Plan says the criteria for the requested treatment have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that surgical treatment of symptomatic varicose veins may 
be indicated when a 3-month trial of conservative therapy such as exercise, periodic leg elevation, weight loss, 
compressive therapy, and avoidance of prolonged immobility where appropriate, has failed. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested vein ablation. Our 
reviewer says that the requested vein ablation is not medically reasonable and necessary. Our physician 
reviewer found coverage criteria require that the enrollee experience symptoms severe enough to impair 
mobility that persist despite a three-month trial of conservative therapy, that typically includes the regular use 
of compressive therapy. In this case, there is no documentation that the enrollee is having limitation in 
mobility, and there does not appear to have been any recent effort at conservative treatment.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested vein ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation of varicose veins.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve a cochlear implant. You say that you need surgery and you did not receive 
this denial until you were on the way to the surgery center. The Plan denied your request. The Plan says the 
documentation does not indicate that you have bilateral sensorineural hearing impairment. 
 The Plan follows Medicare rules. Medicare rules say that in order for cochlear implantation to be covered, you 
must have a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit 
from appropriate hearing (or vibrotactile) aids. 
 
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 cochlear implant. Our reviewer says 
that you do not meet criteria for cochlear implantation. Our physician reviewer found the provided records in 
this case do not document a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with 
limited benefit from appropriate hearing (or vibrotactile) aids as required. The provided records document 
severe rising to moderately severe right sided sensorineural hearing loss and normal to moderate high 
frequency hearing loss on the left. 
 
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 cochlear implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cochlear implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this specific type of ventilator is needed. The 
Plan denied your request. The Plan says the criteria for a ventilator are not met. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable and necessary. Our physician reviewer found the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode which could 
be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral knee braces (L1843) with suspension sleeves 
(L2397) and pelvic control (L2624) provided on October 5, 2022. 
 
You asked the Plan to pay for the knee braces with accessories. You say that this brace was medically 
necessary and should be covered. The Plan denied your request. The Plan says the knee braces were not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace such as those described by code L1843 
may be covered after surgery, knee injury, or with documented joint instability.  
 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 knee braces with accessories. Our 
reviewer says that the records do not support that the criteria for the knee braces have been met. Our physician 
reviewer found the enrollee has chronic pain but does not have recent surgery, knee injury or knee instability at 
the time of the delivery. 
 
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 knee braces with accessories have not been met. Therefore, we decided that 
the Plan does not have to pay for the bilateral knee braces (L1843) with suspension sleeves (L2397) and pelvic 
control (L2624) provided on October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a permanent implantable defibrillator 
system. 
 
You asked the Plan to pre-approve insertion of a permanent implantable defibrillator system. You say that this 
device is medically necessary. The Plan denied your request. The Plan says the patient does not meet medical 
necessity criteria for this device. 
 
The Plan follows Medicare rules. Medicare rules say that implantable cardiac defibrillators are only covered 
when medically necessary and certain clinical criteria are met. 
 
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 insertion of a permanent implantable 
defibrillator system. Our reviewer says that the requested implanted defibrillator is not medically necessary. 
Our physician reviewer found this patient, whose recent ejection fraction by echocardiogram was 50%, is 
without reported sustained ventricular tachycardia. Review of clinical documents does not show that the patient 
meets implant criteria for defibrillator insertion according to current guidelines. In the absence of such 
documentation, implantation of an automatic defibrillator would not be considered medically necessary in the 
management of this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a permanent implantable defibrillator system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a permanent implantable 
defibrillator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab treatments. 
 
You asked the Plan to pre-approve the requested use of pembrolizumab. You say that it is felt that this 
treatment should be tried. The Plan denied your request. The Plan says there is not enough evidence found in 
the medical literature to show that pembrolizumab improves outcomes for patients with the member's specific 
clinical scenario. 
 
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 requested use of pembrolizumab. 
Our reviewer says that the requested use of pembrolizumab is not medically reasonable and necessary. Our physician reviewer found the enrollee had progression of disease while on maintenance durvalumab. Use of 
pembrolizumab after progression on of disease on a prior immunotherapy is not indicated and is not 
recommended in major drug compendia or the National Comprehensive Cancer Network (NCCN) Guidelines. 
The service 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 the requested use of pembrolizumab have not been met. Therefore, we decided 
that the Plan does not have to pre-approve pembrolizumab treatments.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services two hours a day. 
 
You asked the Plan to pre-approve the aide services. You say that the requested aide services are 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 HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 aide services. Our reviewer says  
 that the services are not medically reasonable and necessary. Our physician reviewer found you do not have 
skilled nursing or therapy needs. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide services two hours a day.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services. 
 
You asked the Plan to pre-approve kyphoplasty services. You say that the enrollee is in severe pain and needs 
to be treated as soon as possible. You say that the clinical information provided supports the need for the 
requested procedure. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures are considered medically 
reasonable and necessary for fractures that have not responded to non-surgical medical management with and 
without methods of immobility.  
 
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 services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation 
of a trial and failure of bracing. More conservative measures are needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty services.