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

 
We decided that the Plan does not have to pre-approve a chemotherapeutic regimen of Tecentriq and Zirabev. 
 
You asked the Plan to pre-approve a chemotherapeutic regimen of Tecentriq and Zirabev. You say that the 
records provided support the need for the requested drugs. The Plan denied your request. The Plan says there is 
not enough evidence found in the medical literature to show that the requested medicines are effective for 
managing the enrollee's condition. 
 
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 a chemotherapeutic regimen of 
Tecentriq and Zirabev. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of recurrent hepatocellular carcinoma. The 
record indicates that the requested regimen is not for first line treatment. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
 
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 chemotherapeutic regimen of Tecentriq and Zirabev have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a chemotherapeutic regimen of Tecentriq and 
Zirabev.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames (V2020) and polycarbonate lenses (V2784) provided on 
February 14, 2022. 
 
You asked the Plan to pay for frames (V2020) and polycarbonate lenses (V2784). You say that you had an eye 
exam, was not satisfied and requested a reimbursement for out-of-pocket amount $54. The Plan denied your 
request. The Plan says that the service is a covered benefit, but the enrollee is disputing the amount assessed by 
the health plan for the copayment. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The covers $100 towards your purchase of frames. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $0 copayment, and you receive a 
$100 allowance toward your purchase of frames. The record shows that the Plan only paid $31 toward the 
eyewear allowance. The purchase of your frames was $130. Although the polycarbonate lenses are not covered 
by the Plan, the cost of the frames alone is still higher than the full eyewear allowance. Therefore, the Plan 
must reimburse you an additional $69 to furnish the full $100 eyewear allowance. Therefore, we decided that 
the Plan has to pay for frames (V2020) and polycarbonate lenses (V2784) provided on February 14, 2022.  
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you have severe chronic respiratory failure 
consequent to chronic obstructive pulmonary disease (COPD.) The Plan denied your request. The Plan says a 
home mechanical ventilator set in pressure support (PS) with Safety Tidal Volume mode that could be 
delivered by bi-level positive airway pressure (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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. You have chronic obstructive pulmonary disease (COPD) and recurrent aspiration 
pneumonia. An arterial blood gas (ABG) done while you were acutely ill with pneumonia was consistent with acute hypercarbic respiratory failure. There is no documentation of chronic carbon dioxide (CO2) retention 
with an ABG while you were stable as an outpatient.  If you do have chronic CO2 retention, you may benefit 
from BiPAP with average volume-assured pressure support (AVAPS) during sleep. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (CPT code 62323). 
 
You asked the Plan to pre-approve the epidural steroid injection. You say that the service is necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the epidural steroid injection. Our 
physician reviewer found the LCD requires 50% pain relief for at least three (3) months. Therefore, the request 
is deemed 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 the epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injection (CPT code 62323).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. The 
Plan says that there is no indication that the preferred drugs would likely be less effective or cause adverse 
effects for the enrollee. 
 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 Aranesp. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs Retacrit 
or Procrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device (E0601). 
 
You asked the Plan to pre-approve continued use of a CPAP device. You say that you did not use the CPAP 
device in the first 30 days. You were having a hard time getting used to it. With your lung problem, it can be 
hard for you. You have been getting pneumonia which is not good, and you need your oxygen to be clean at all 
times. The Plan denied your request. The Plan says criteria is not met so continued coverage of a PAP device 
and related accessories are denied as not reasonable and 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 continued use of a CPAP device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no follow up visit with the provider to assess use and benefit.  The 
Compliance Report shows usage is not sufficient to meet minimum criteria, or to be of significant benefit. You 
used the device at least 4 hours/night for 24% of nights; minimum Medicare criterion is at least 70% of nights. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a CPAP device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued use of a continuous positive airway pressure (CPAP) device 
(E0601).
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 if you wait long for transfer you can be 
exposed to germs and ailments that are in the hospital setting. You say that your wound needs to be treated 
daily and your spinal infection gives you limited mobility. You say that you are bedridden and are using a 
machine to keep fecal matter away from your wound and to aid in healing. The Plan denied your request. The 
Plan says the records do not show that you require continued treatment that can only be given in a hospital 
setting. The Plan says that your continued care needs include antibiotics and wound care. The Plan says that 
when you are ready to leave the hospital, you can safely receive this care in another setting. 
 
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 you were admitted with increased confusion. You were somnolent with no interaction 
and had encephalopathy. You had previously been treated for a psoas abscess and you also had a wound 
dehiscence to surgical incision.  You also had 2 days bradycardia down to the 30's as well as a high potassium level. There is no documentation 
provided indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the 
present acute care hospital. There are no services available at the LTACH that you require that are not available 
at the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 pay for four units each of procedure codes 73610 and 73630 billed 
for date of service March 7, 2022. 
 
You asked the Plan to pay for procedure codes 73610 and 73630. You say that these services are supported in 
the medical records provided. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules, and the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. When a 
procedure is performed bilaterally and the HCPCS code descriptor does not state that it is a unilateral or 
bilateral procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit 
of service. Medicare rules also say that claims submitted where the unit of service exceeds the MUE value are 
medically highly unlikely to have been reported correctly and been medically necessary when the MAI is 3.  
 
We looked at the file and Medicare rules. Four units of 73610 and four units of 73630 were billed for the date 
in question. Two units of each code were billed using the LT modifier and two units of each code were billed 
using the RT modifier. In addition, each of these codes has an MUE of 3 and an MAI of 3. It would be more 
appropriate to use the 50 modifier and bill fewer units of service in this case. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 73610 and 73630 have not been met. Therefore, 
we decided that the Plan does not have to pay for four units each of procedure codes 73610 and 73630 billed 
for date of service March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 You asked the Plan to pre-approve Neulasta. You say that the requested drug is medically necessary for 
treatment of the enrollee's lung cancer. The Plan denied your request. The Plan says the enrollee is in a clinical 
trial and Original Medicare covers routine costs associated with clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Neulasta as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Neulasta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe chronic 
obstructive pulmonary disease (COPD) with a recent exacerbation that did not require hospitalization. There is 
no documentation of chronic carbon dioxide retention on an arterial blood gas study done while stable. 
Medicare does not cover a home ventilator when used as bi-level positive airway pressure (BiPAP). The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the records do not support the services billed. 
 
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 April 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial and have submitted 
additional information. The Plan denied your request. The Plan says based on Medicare rules and the enrollee's 
care needs, we are denying coverage for this admission or transfer to SNF. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was at a stand-by assist to independent level with functional mobility 
including gait to 50 feet. The enrollee required varying assists with activities of daily living skills. The enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that an intensive 
rehabilitation program 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found encephalopathy is an IRF compliant diagnosis. Our reviewer found that the clinical documentation 
shows that the enrollee has multiple active complications and comorbidities, thus would be expected to require 
close medical supervision on an inpatient basis. Our physician reviewer also found that evaluating therapists 
state that the enrollee will benefit from and recommend intense therapy. Therefore, IRF criteria has been met 
and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.