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

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that Vabysmo is medically necessary. The Plan denied 
your request. The Plan says a trial of Bevacizumab is required before alternatives can be considered. 
 
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 Vabysmo. Our reviewer says that 
Vabysmo is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason they are unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs around the clock 
assistance to help with activities of daily living. You say that the enrollee has a large wound that requires daily 
physician oversight. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee' s needs can be met at an alternate level of care. 
 
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 that there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. 
 
   
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has a vertebral 
compression fracture that was first documented more than 12 weeks ago on September 6, 2022. The fracture is 
not acute or subacute, as defined in the coverage rule. The elements of the coverage criteria are not satisfied 
and the PVA is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the NeuroTraxTM automated test. 
 
You asked the Plan to pre-approve the NeuroTraxTM automated test. You say that the NeuroTraxTM automated 
test is medically necessary. The Plan denied your request. The Plan says the NeuroTraxTM automated test 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 NeuroTraxTM automated test. Our 
reviewer says that the requested NeuroTraxTM automated test is not considered medically reasonable and 
necessary. Our physician reviewer found that the clinical utility and impact of such testing is not well 
established 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 NeuroTraxTM automated test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the NeuroTraxTM automated test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is currently in the hospital and 
currently on a ventilator. The enrollee will die without it and the hospital will not let her go home without it. 
The Plan denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode 
with Auto-EPAP(AE) that could be delivered by BiPAP is not covered. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
coverage for such a device is available upon request. The elements of the coverage criteria are not satisfied. 
The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardiac monitor (ICM). 
 
You asked the Plan to pre-approve an ICM. The Plan denied your request. The Plan says  
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are covered for the 
indications established in the applicable NCD. 
 
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 ICM. Our reviewer says that an ICM 
is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent 
indication for an ICM. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ICM in this enrollees clinical management. 
 
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 ICM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable cardiac monitor (ICM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EGD, flexible, transoral; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (43235). 
 
You asked the Plan to pre-approve the EGD. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the enrollee has no indication for an EGD. 
 
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 EGD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request is for a repeat EGD for cancer screening due to family history (father) of gastric 
cancer. However, no current guidelines indicate EGD for only family history of gastric cancer, particularly 
when one was already performed, such as in this case. There is no standard EGD surveillance recommended for 
this clinical situation based on current evidence. Therefore, this request for EGD will be considered 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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve EGD, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or 
washing, when performed (43235).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and accessories 
(E0108, E1028). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the 
documentation does not reveal that you have a mobility limitation that significantly impairs MRADLs. You are 
independent in toileting, feeding, dressing, grooming, and have a personal care assistant for bathing. The 
documentation does not reveal that you are unable to use an assistive device or that the use of a Group 2 power wheelchair will significantly improve MRADLs in the home. While you may be able to use the power 
wheelchair the documentation does not reveal that it is medically necessary. As the power wheelchair is not 
medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and accessories (E0108, 
E1028).
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 provided records do not explain what care services will be provided in the 
LTACH that are not available in the present hospital setting. Continued care in the short-term acute hospital is 
appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation 
facility, a sub-acute rehabilitation facility or a skilled nursing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
the enrollee has an appropriate diagnosis and testing with history to qualify for coverage for the device. The 
Plan denied your request. The Plan says records do not show that the requested device will not be used 
exclusively in bi-level PAP mode. The ventilator was ordered in a mode called volume assured pressure 
support (VAPS), and this can be achieved with bi-level devices such as a BiPAP machine. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee was successfully treated with BiPAP and AVAPS. The provided primary source documentation does 
not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage for such a 
device is available upon request. The elements of the coverage criteria are not satisfied. The requested service 
cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional twenty-four (24) physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the 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 Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollee's condition beyond what was approved by the Health Plan. The enrollee 
has had prior extensive therapy and the documentation does not reveal that the enrollee requires the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has had 
instruction on a home exercise program. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional twenty-four (24) physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0885), 200mcg every 2 weeks. 
 
You asked the Plan to pre-approve Aranesp. You say that you are trying to avoid blood transfusions for the 
enrollee as they have a history of a kidney transplant. The Plan denied your request. The Plan says the 
requested dosage and frequency exceeds the Food and Drug Administration (FDA) labelled recommendations. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Aranesp. Our reviewer says that the 
requested drug, Aranesp, is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the requested drug is indicated for the enrollee's condition. The reviewer found that the enrollee 
has a serum creatinine level of 0.80 mg/dL and an estimated glomerular filtration rate (eGFR) greater than 60 
mL/minute/1.73 meters^2. The reviewer found that Aranesp is not indicated when the eGFR is greater than 60. 
Therefore, the reviewer found that the requested drug is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0885), 200mcg every 2 weeks.
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 requested admission to an IRF does not meet 
criteria. 
 
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 were admitted for altered mental status, bradycardia and hypothyroidism. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda 100MG/4ML vial (J9271). 
 
You asked the Plan to pre-approve the medication. You say that the enrollee is not a good candidate for 
additional chemotherapy. The Plan denied your request. The Plan says the medication 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 the medication. Our physician reviewer 
found the requested use of Keytruda is not FDA-approved for the enrollees diagnosis. First-line, single-agent 
treatment of metastatic or unresectable recurrent head and neck squamous cell carcinomas (HNSCCs) in 
patients whose tumors express PD-L1 (CPS greater than or equal to 1), as determined by an approved test. The 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS)-approved medical journal (see appendix for list of CMS-approved 
journals).  
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda 100MG/4ML vial (J9271).