Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services (G0151) and direct skilled 
nursing services of a registered nurse (RN) (G0299) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services and direct skilled nursing services of an RN. The 
Plan denied your request. The Plan says based on Medicare guidelines, the request to use an OON provider for 
services does not meet the requirements for approval. The Plan also says that these services were ordered from 
an OON provider, and there are 105 in-network home health agencies within 20 miles. 
 
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 
physical therapy services (G0151) and direct skilled nursing services of a registered nurse (RN) (G0299) to be 
provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections. 
 
You asked the Plan to pre-approve sacroiliac joint injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says this does not meet the criteria for coverage. 
 
 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 sacroiliac joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the physical exam does not have 
3 diagnostic provocative diagnostic tests documented. The LCD requires the documentation to include at least 
3 diagnostic maneuvers. Therefore, the request is deemed not medically reasonable and 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 sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that this is medically necessary. 
The Plan denied your request. The Plan says this 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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental. It is the subject of ongoing 
clinical trials. Therefore, the request is deemed not medically reasonable and 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the positron emission tomography (PET) scan with computed 
tomography (CT) from skull base to mid-thigh. 
 
You asked the Plan to pre-approve the PET image with CT scan. You say that  the service is medically 
necessary.  The Plan denied your request. The Plan says that the PET image with CT scan is not medically 
necessary. The Plan says that a stable pulmonary nodule that has already been evaluated with PET/CT would 
not qualify as strongly suspected. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET image with CT scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has a history 
of smoking and a high risk for lung cancer. This case is somewhat unique since the first PET/CT was 
borderline in metabolic activity. The radiologist interpreting the CT scan on April 2023 advised a six-month 
CT surveillance but the decision to go forward with invasive biopsy versus CT surveillance will hinge on the 
PET/CT results. Thus, the request for a second PET/CT in an enrollee with high suspicion of malignancy is 
reasonable and should be approved.  
 
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 PET image with CT scan have been met. Therefore, we decided that the 
Plan has to pre-approve the positron emission tomography (PET) scan with computed tomography (CT) from 
skull base to mid-thigh.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve optimizer smart implantable pulse generator. 
 
You asked the Plan to pre-approve optimizer smart implantable pulse generator. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve optimizer smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has left ventricular dysfunction with 
continued symptoms, despite medical treatment, thought to reflect congestive heart failure. While the clinical 
studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, 
the enrollee does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of optimizer smart implantable pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve optimizer smart implantable pulse generator.
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. You say that the enrollee suffers from extreme pain which has 
affected their activities of daily living and quality of life. You say that the previous injections have proven to 
resolve the enrollee's radicular pain for a significant amount of time. The Plan denied your request. The Plan 
says an 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 an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the epidural steroid 
injection in March of 2023 provided only one day of relief. However, the LCD requires at least 50% pain relief 
for three months after an epidural steroid injection, which was not achieved. Therefore, the request is not 
medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invitae APC Gene full sequence panel testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the records show you do not personally have cancer. 
 
The Plan follows Medicare rules. Medicare rules state that lab testing for inherited cancer syndromes may be 
covered if specific 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 genetic testing. Our reviewer says that 
you do not meet criteria for this testing. Our physician reviewer found you have no personal history of cancer 
so do not meet the coverage indications for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Invitae APC Gene full sequence panel testing.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. You asked the Plan to pre-approve Hymovis. 
You say that Synvisc-One is not a preferred agent in your office. You also say many of your patients 
experience side effects from Synvisc-One and this is not appropriate for the enrollee due to its lower molecular weight. The Plan denied your request. The Plan says no information stating the enrollee has tried the 
prescription drug alternative, Synvisc-One, has been received.  
 
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 Hymovis. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 16, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. 
The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, the CPT Code Manual definition of code 96521 is refilling and maintenance 
of portable pump. We find that CPT code 96521 is not supported in the medical record. The records show that 
an order was placed, but the records do not show the services were provided. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panniculectomy. 
 
You asked the Plan to pre-approve the panniculectomy. You say that the surgery is medically necessary.  The 
Plan denied your request. The Plan says the panniculectomy is not medically necessary. The Plan says the 
enrollee's pannus is not hanging below the pubic bone and there is no chronic skin rash.  
 
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 panniculectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has lipodystrophy. The record provided does not 
document the presence of chronic intertrigo refractory to conservative management or functional impairment. 
The elements of the coverage criteria are not satisfied, and the requested service is not 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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the panniculectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the codes. The Plan 
denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, the CPT Code Manual definition of code 96521 is refilling and maintenance 
of portable pump. We find that CPT code 96521 is not supported in the medical record. The records do not 
document this service was provided. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the Outpatient Intravenous 
Insulin Therapy (OIVIT) services provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that there is strong evidence to support the 
use of proton therapy for prostate cancer. The Plan denied your request. The Plan says this is not the standard 
of care for prostate cancer and should only be performed in the context of a prospective 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while proton therapy may not be an experimental therapy, any potential benefit or 
detriment of proton therapy compared to standard treatment is an investigational question. There is no 
compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy (IMRT)/image-guided radiation therapy (IGRT). The generally accepted standard of care for 
prostate cancer is to only offer proton beam therapy on clinical trials and to not routinely offer it to patients. 
 
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 therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic side guards (K0108). 
 
You asked the Plan to pre-approve plastic side guards. You say that the items should be covered. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpse. 
 
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 plastic side guards (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kimyrsa. 
 
You asked the Plan to pre-approve Kimyrsa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the criteria for approval of the requested drug have 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 Kimyrsa. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found there is no documentation 
demonstrating that all appropriate empiric antibiotics for treatment of lower left extremity cellulitis have been 
tried. The review indicates that Kimyrsa is indicated for the treatment of acute bacterial skin and soft structure 
infection (ABSSSI), especially with the rise of antimicrobial resistance among Gram-positive bacteria. The 
review has determined that the documentation does not support that Kimyrsa is medically reasonable and 
necessary for the patient. The documentation does not support that the Kimyrsa is safe and effective for the 
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 Kimyrsa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kimyrsa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance provided on May 13, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the supply allowance. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the supply allowance is not covered when provided 
by an out-of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network diabetes self-management training, diabetic 
services, and supplies are not covered. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the supply allowance provided on May 13, 2023, 
by an OON provider.
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 the IRF care is needed to help you regain strength. 
You say that you cannot stand up or walk on your own.  The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing 
facility.  
 
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 you require assistance for bed mobility and transfers. You are ambulating with a 
rolling walker and minimal assistance following hospitalization for acute on chronic bilateral lower extremity 
weakness attributed primarily to diabetic polyneuropathy. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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.