Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.
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 an office visit provided on February 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 the laboratory services provided on February 11, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277), for the 
enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the site of the wound is not on your trunk or pelvis. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the DME have not been met. Records show a group II support surface is being requested for a 
healing wound on the enrollee's left heal. The site of the wound is not on the enrollee's trunk or pelvis. 
Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air mattress 
(E0277), for the enrollee.
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 LTACH services are medically 
necessary The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 requires acute care services in the short-term but will be stable enough 
for lower-level care and long-term placement soon. The enrollee does not require any services at the proposed 
LTACH that are not already being provided at the current facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee had x-rays of the hands which showed 
bilateral severe arthritic changes of the 3rd MCPs. You say that the enrollee is currently on treatment, but had 
to stop certain RA medications due to concerns of clots in her legs. You say that the enrollee has been having 
increased pain. You say that you want to investigate further on the erosions shown on the x-rays to help 
determine the next step for the enrollee. The Plan denied your request. The Plan says the medial information 
received does not show that the criteria for an MRI of both hands have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis 
(RA) and gout. The enrollee had x-ray findings of mild joint disease in the hands from June 16, 2020, including 
moderately severe arthritis changes in the metacarpophalangeal joint of the third digit with marginal 
osteophytes suggestive of gouty changes. She had recently stopped Rinvoq treating her rheumatoid arthritis due 
to concerns for clots in her legs. She is still taking leflunomide and prednisone, however. MRI of the bilateral 
hands was requested for monitoring of her arthritis. Her RF is elevated at 76 but ESR and CRP were normal. 
Vectra DA score is 19 suggestive of current symptoms not being related to RA. The notes in this case do not 
suggest plans or consideration for changing her medication regimen for her RA making the MRI not clinically 
relevant. Also, repeat x-ray of the hand in question (right third digit) was not performed and would be most 
appropriate next imaging step considering symptoms likely related to gout. Therefore, this request for MRI 
bilateral hands is not supported and will be considered not medically necessary at this time as it would not 
likely lead to a significant change in clinical treatment or outcome in this patient's specific situation. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) services.
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 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 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that 
you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 
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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan. 
 
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their 
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 MRIs are covered only when they are medically 
necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
the plan to support that the requested MRI services are medically reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of an MRI scan have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expanded controller (E2311). 
 
You asked the Plan to pre-approve the expanded controller. You say that the records provided support the need 
for the item being requested. The Plan denied your request. The Plan says the upper extremity strength and 
function are adequate for the enrollee to be able to control the power options using their own switches, which 
are included in the allowance of the power options. 
 
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 expanded controller. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 72-year-old woman with a history of stroke, diabetes, hypertension, 
and chronic kidney disease. Her left upper extremity strength is noted to be 3/5, and her right upper extremity 
strength is noted to be within normal limit. Code E2311 describes the electronic components that allow the 
beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, 
touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear 
reduction, power leg elevation, power seat elevation, power standing. The documentation does not support that 
it is medically necessary for the enrollee to control the power options through a drive interface. 
 
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 expanded controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expanded controller (E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve the Pembrolizumab (Keytruda). You say that the record provided support 
the need for the requested drug. The Plan denied your request. The Plan says the addition of Keytruda is not 
recommended at this time and the guidelines for coverage have not been met 
 
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 Pembrolizumab (Keytruda). Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does 
not have metastatic disease and has not failed 1st line therapy, despite high tumor mutational burden. The use 
of Keytruda in this instance is not supported by one of the major drug compendias or by clinical research that 
appears in a CMS-approved medical journal. 
 
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 Pembrolizumab (Keytruda) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Pembrolizumab (Keytruda).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg. 
 
You asked the Plan to pre-approve a prosthetic leg. You say that the enrollee is having complications with the 
amputation stump. You say that the enrollee has needed this prosthetic leg for a few months now and that it is 
hard for him to transport without it. The Plan denied your request. The Plan says a prosthesis replacement is not 
medically necessary. The Plan says that the prosthesis should be evaluated by the DME provider to determine 
whether it should be repaired or replaced. The Plan says that the notes do not say the enrollee will be able to 
reach a functional state. The Plan says that the notes do not say a projected timeline. 
 
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 prosthetic leg. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the criteria for coverage have been met. The enrollee 
has multiple lower extremity ulcers and requires podiatry and dermatology referrals. There is no evidence that 
the enrollee will reach or maintain a defined functional state within a reasonable period of time in the submitted 
documentation. 
 
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 prosthetic leg have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg.
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 admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary. The Plan denied your 
request. The Plan says the enrollee must have had prior therapy or an inability to use either Remicade or 
Infectra and Stelara. 
 
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. Medicare rules also say that the requesting provider must supply information that 
corroborates the documentation in the beneficiary's medical documentation and confirms that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. The case file did not include medical records which showed the 
enrollee has tried and failed treatment with Remicade or Inflectra and Stelara. The case file did not include any 
information showing that these required drugs would likely be less effective and/or likely to have adverse 
effects for the enrollee. Based on this information, we decided that Medicare rules for coverage of Entyvio 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vedolizumab injection services. 
 
You asked the Plan to pre-approve the vedolizumab injection services. You say that the services in dispute are 
medically necessary. The Plan denied your request. The Plan says there is no documentation of a three month 
trial of a tumor necrosis factor blocker or that a trial is contraindicated. The Plan says that the enrollee has 
documentation of an adequate response to corticosteroid, but has not demonstrated dependence due to recent 
diagnosis of disease. 
 
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 the vedolizumab injection services. Our 
reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found 
the enrollee was diagnosed with colonic Crohn's disease, based on hospitalization earlier this month, 
colonoscopy findings, a rule out of small bowel involvement per MR enterography, and her clinical response to 
corticosteroids. Initial concern was prompted by CT abdomen/pelvis on August 8, 2020 that demonstrated 
colonic distension and colon wall thickening with skip areas, peri-colonic adenopathy, along with diverticulosis 
but no evidence of diverticulitis. The enrollee's provider has proposed initiation of Entyvio for long-term 
management of enrollee's IBD which, although improved symptomatically, is still associated with 2-3 loose 
stools daily without blood. Entyvio (vedolizumab) is a humanized monoclonal antibody. Vedolizumab targets a 
protein called alpha-4-beta-7, an integrin on inflammatory cells that causes these cells to adhere to the 
gastrointestinal tract. Entyvio is specifically indicated for adults with moderately to severely active ulcerative 
colitis (UC) or Crohn's disease (CD) who have had an inadequate response with, lost response to, or were 
intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, 
were intolerant to, or demonstrated dependence on corticosteroid. Entyvio is indicated to induce and maintain 
clinical response/clinical remission, achieve corticosteroid-free remission and improve the endoscopic 
appearance of the mucosa. While the enrollee has Crohn's disease, she does not meet the FDA Entyvio 
indications, and as such alternative treatment options should be considered. These FDA Entyvio indications 
include prior anti-TNF blocker failure, prior immunomodulator failure, and corticosteroid dependency. 
 
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 vedolizumab injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve vedolizumab injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Home Ventilator (CPT E0466).
You asked the Plan to pre-approve a Home Ventilator. You say that the clinical notes document the medical
necessity for the requested item. The Plan denied your request. The Plan says the enrollee's doctor has
prescribed a ventilator to help with breathing at various times of the day and night because of lung disease. The
Plan says that Medicare does not cover ventilators used this way. The Plan says that Medicare will cover a
device called respiratory assist device that has advanced features, and that the Plan ill cover this when
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 Home Ventilator. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has COPD with chronic hypoxic and hypercarbic respiratory failure. Chronic
narcotic therapy may be contributing to the hypercarbia, and obstructive sleep apnea does not appear to have
been considered. In any case, Medicare does not cover a home ventilator when used as BiPAP. In this case, the
home ventilator being requested would be used as BiPAP. Certain BiPAP devices are capable of providing the
AVAPS-AE mode of support, if 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 Home Ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Home Ventilator (CPT E0466).