Persius/hicric huggingface dataset:
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 device is medically necessary. 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 provided medical records document a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-
up rate. As stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide 
CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Trimethylaminuria FMO3 single gene testing (81479). 
 
You asked the Plan to pay for Trimethylaminuria FMO3 single gene testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is not listed in the DEX database covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing billed have not been met.  
Therefore, we decided that the Plan does not have to pay for Trimethylaminuria FMO3 single gene testing 
(81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection (64494). 
 
You asked the Plan to pre-approve the injection. You say that you have severe impingement which presses on 
your nerves causing pain. You also say that your magnetic resonance imaging (MRI) confirms you have spinal 
stenosis. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria. 
 
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 the requested facet joint injection is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate a trial and failure of recent, reasonable, comprehensive less invasive 
conservative care measures. The reviewer found that a formal magnetic resonance imaging (MRI) is not 
provided to corroborate facet pathology. Therefore, the reviewer found that the requested facet joint injection is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection (64494).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that use of wireless capsule endoscopy is indicated 
only if EGD and colonoscopy has been done within the past 12 months and failed to identify a bleeding source.  
 
   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a wireless capsule endoscopy have not been met. Specifically, the medical records show that the 
enrollee has not had an EGD or colonoscopy within the past 12 months. Therefore, we decided that the Plan 
does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerendia (finerenone) 10mg tablets. 
 
You asked the Plan to pre-approve the Kerendia tablets. You say that this drug is medically necessary. The 
Plan denied your request. The Plan says this oral drug cannot be covered by Medicare Part B. 
 
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 Kerendia (finerenone) 
10mg tablets.  
 
Benefits for the Kerendia 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation in a luxury car provided on February 28, 2022. 
 You asked the Plan to pay for luxury car transportation. You say that you have limited transportation options in 
your area, and this is what was available. The Plan denied your request. The Plan says this transportation is not 
covered by Medicare or by your plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit for transplant-related services that exceeds Medicare coverage. For that reason, the Plans 
coverage rules apply in this case. The Plan covers certain costs for transportation related to transplant care. 
Luxury car and limousine services are not eligible for reimbursement.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the service at issue 
is luxury car transportation. Therefore, we decided that the Plan does not have to pay for transportation in a 
luxury car provided on February 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that a 
HFCWOD is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a chronic cough and sputum cultures positive for MAI. The physician's notes indicate a diagnosis of bronchiectasis, but this is not documented on any imaging report. There is no diagnosis of cystic fibrosis or 
neuromuscular disease. The enrollee does not have a diagnosis for which Medicare covers HFCWOD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
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 medically necessary to receive the 
care needed to help you get back to your normal life. The Plan denied your request. The Plan says you do not 
require the requested 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 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 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's medical problems are stable and there are no complex nursing or rehabilitation needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-ventricle pacemaker (33208, 33225, C1779, C1785, 
C1898, C1900, C2619). 
 
You asked the Plan to pre-approve a bi-ventricle pacemaker. You say that the requested procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 bi-ventricle pacemaker. Our reviewer 
says that the requested implantation of a bi-ventricle pacemaker is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation does not indicate any left 
ventricular dysfunction is present. Therefore, the reviewer found that there is insufficient documentation to 
support the medical necessity for implantation of a bi-ventricular pacemaker 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 a bi-ventricle pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bi-ventricle pacemaker (33208, 33225, C1779, C1785, C1898, C1900, C2619).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluorouracil, Eloxatin, Imfinzi, and Leucovorin use in 
combination with related services Decadron. 
 
You asked the Plan to pre-approve fluorouracil, Eloxatin, Imfinzi, and Leucovorin use in combination with 
related services Decadron. You say that the service is medically necessary. The Plan denied your request. The 
Plan says the service 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 fluorouracil, Eloxatin, Imfinzi, and 
Leucovorin use in combination with related services Decadron. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the requested use of this drug is not FDA-approved for the 
enrollees diagnosis and the use is not supported by one of the major drug compendia 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 fluorouracil, Eloxatin, Imfinzi, and Leucovorin use in combination with related 
services Decadron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
fluorouracil, Eloxatin, Imfinzi, and Leucovorin use in combination with related services Decadron.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve darzalex (J9145) and carfilzomib (J9047). 
 
You asked the Plan to pre-approve darzalex and carfilzomib. You say that the requested drugs are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested drugs are 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 darzalex and carfilzomib. Our reviewer 
says that the requested drugs, darzalex and carfilzomib, are not medically necessary. Our physician reviewer 
found the provided documentation does not indicate that the requested use of darzalex and carfilzomib are 
FDA-approved for the enrollees diagnosis. The reviewer found that the requested use is not supported by the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal either. 
Therefore, the reviewer found that the requested drugs are 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 darzalex and carfilzomib have not been met. Therefore, we decided that the 
Plan does not have to pre-approve darzalex (J9145) and carfilzomib (J9047).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 13, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the enrollee is functioning very near a community level for rehabilitation. The 
enrollee does not have intensive or complex needs and does not require physiatry oversight. 
 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac catherization (93458). 
 
You asked the Plan to pre-approve the cardiac catherization. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 cardiac catherization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient had two negative stress tests and guidelines do not support a need for 
cardiac catheterization in this setting. 
 
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 cardiac catherization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the cardiac catherization (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the clinical documentation shows functional impairments however there are no 
complex functional deficits or active medical issues specified thus the complexity of the enrollee's documented  nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care physician (PCP) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PCP services. You say that this was your PCP under your previous plan. 
You say that you would like to continue seeing them. You also say that the provider is Asian and can 
understand you. The Plan denied your request. The Plan says the requested PCP services are available in-
network. 
 
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 confirmed there are 
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 primary care physician (PCP) 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 an expandable controller and power seat elevation 
system for a power wheelchair (E2377, E2313, E2311, E2300). 
 
You asked the Plan to pre-approve the expandable controller and power seat elevation system. You say that 
these features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary. The rules also state that a power seat elevation feature is non-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 expandable controller and power 
seat elevation system. Our reviewer says that these features are not medically necessary. Our physician 
reviewer found the records show that the enrollee has adequate upper body strength to manage standard power 
drive switches. The power seat elevation feature is non-covered by Medicare rules. 
 
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 expandable controller and power seat elevation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller and power seat 
elevation system for a power wheelchair (E2377, E2313, E2311, E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 24, 2022.