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

 
We decided that the Plan does not have to pre-approve Pertuzumab/Trastuzumab combination therapy. 
 
You asked the Plan to pre-approve Pertuzumab/Trastuzumab combination therapy. You say that the requested 
Pertuzumab/Trastuzumab combination therapy is medically necessary. The Plan denied your request. The Plan 
says the requested Pertuzumab/Trastuzumab combination therapy is not medically necessary. 
 
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 Pertuzumab/Trastuzumab combination 
therapy. Our reviewer says that the requested Pertuzumab/Trastuzumab combination therapy is not medically 
necessary. Our physician reviewer found this review relates to a request for Pertuzumab and Trastuzumab to 
treat the enrollee with HER2neu positive metastatic cholangiocarcinoma. The requested combination is not 
FDA approved for this use. The combination is not supported in any of the CMS approved compendia. The 
prescriber submitted medical literature in support of the request. The submitted articles include case reports, 
preliminary data in abstract form, are preclinical information, or not reflective of the enrollee's clinical 
situation.  Therefore they do not meet CMS criteria for support of a medically accepted use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pertuzumab/Trastuzumab combination therapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Pertuzumab/Trastuzumab combination therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioventus Osteoamp allograft. 
 
You asked the Plan to pre-approve a Bioventus Osteoamp allograft. You say that the requested Bioventus 
Osteoamp allograft for the approved surgery is medically necessary. The Plan denied your request. The Plan 
says the requested Bioventus Osteoamp allograft for the approved surgery 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 Bioventus Osteoamp allograft. Our 
reviewer says that the requested Bioventus Osteoamp allograft for the approved surgery is not medically 
necessary. Our physician reviewer found the enrollee is diagnosed with several canal stenosis resulting in 
cervical myelopathy. The physician requested for the enrollee to undergo PCDF of C2-C6 which has been 
approved by the Plan. The allograft requested for the approved surgery is experimental. More research is 
needed to show safety and efficacy of the allograft product in spine surgery. 
 
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 Bioventus Osteoamp allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Bioventus Osteoamp allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil tablets. 
 
You asked the Plan to pre-approve Tadalafil tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Tadalafil tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Tadalafil tablets.  
 
Benefits for Tadalafil tablets 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Medicare does not cover PET imaging for initial anti-
tumor strategy for prostate cancer patients. 
 
The Plan must follow Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is 
non-covered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pre-
approve a PET/CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network providers available to the 
enrollee that can provide the care and treatment being requested. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reclining chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not primarily medical in nature. 
 
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 reclining chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 24 one-way trips and 
additional trips cannot be provided. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need for daily skilled nursing or therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that you 
require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse is not required to safely and effectively provide medically necessary and reasonable treatment. You do 
not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist 
is not required to safely and effectively provide medically necessary and reasonable treatment. Based on the 
medical records provided you do not require the services on an inpatient basis, in a skilled nursing facility 
setting. Services in the home with home health services or in a long-term care facility on a part time basis 
appears appropriate 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crestor (J8499) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Crestor (J8499) for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to an inpatient hospital for a thyroidectomy. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are no acute or active comorbidities that would indicate any possible 
complications from this ambulatory (day) surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case has active medical 
problems that would necessitate inpatient admission for this enrollee who is to undergo thyroid surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for admission to an inpatient hospital for a thyroidectomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flex injections, for the enrollee. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says this drug is self-administered (covered under 
pharmacy benefit); however, this plan does not include a pharmacy or drug plan. The Plan states the enrollee 
has another pharmacy benefit and you should reach out to them. 
 
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 Tresiba Flex injections, for 
the enrollee.  
 
Benefits for the self-administered drugs 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 above. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for treatment of infected left hip 
prosthesis. He will require 8 weeks of intravenous antibiotics. There are no complex nursing or rehabilitation 
needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The record does support a need for physical and 
occupational therapy but there is no need for an intensive rehabilitation program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the A1C testing rendered on January 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, A1C levels, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
A1C testing rendered on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 17, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 20, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary, rest home visit (99336) provided on February 5, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary, rest home visit. You say that the enrollee was in an assisted living 
facility the time services were rendered. Your company has an exclusive contract with the facility for your 
doctors to provide dermatology care. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider. Non-emergent services with non-contracted providers require 
prior-authorization prior to services being rendered. 
 
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 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. 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 domiciliary, rest home visit (99336) provided on 
February 5, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on April 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on November 25, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare has established limited diagnosis code 
coverage for procedure code 00731. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 00731 with 
diagnosis codes K21.9, K29.00, K29.80, and K22.10. These codes are not listed in the Medicare rules as those 
supporting medical necessity. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services rendered on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an application of an Unna boot (29580) 
performed on March 5, 2020. 
 
You asked the Plan to waive the copayment for an application of an Unna boot. You say that you should only 
be charged the copayment for an office visit. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay $126.72 for an application of an Unna boot. An application of an Unna boot falls 
within the Outpatient surgery benefit category. This means that you have been asked to pay less than the full 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an application of an Unna boot (29580) performed on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The Plan must follow Medicare rules. Medicare 
rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an 
enrollee for a specific medical problem. 
 
We find that HCPCS code G0483 is not supported in the medical record. The file does not contain 
documentation of an established relationship between the enrollee and the ordering provider. Without a record 
showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to 
the enrollee.