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

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Carboplatin (J9045), Gemcitabine 
HCL (J9201), and Dexamethasone Sodium Phosphate (J1100). 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Gemcitabine HCL, and Dexamethasone Sodium 
Phosphate. You say that this is medically necessary. The Plan denied your request. The Plan says the requested 
use of this drug combination is not supported. 
 
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 Keytruda, Carboplatin, Gemcitabine 
HCL, and Dexamethasone Sodium Phosphate. Our reviewer says that the requested drug combination is not 
supported. Our physician reviewer found the record indicates that the enrollee has a diagnosis of metastatic 
squamous non-small cell lung cancer. The Food and Drug Administration has not stated that the requested drug 
regimen is indicated for the enrollee's specific condition. The Medicare-approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's specific clinical 
situation. No literature from Medicare-approved cancer journals was 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 Keytruda, Carboplatin, Gemcitabine HCL, and Dexamethasone Sodium 
Phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda 
(J9271), Carboplatin (J9045), Gemcitabine HCL (J9201), and Dexamethasone Sodium Phosphate (J1100).
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 pulmonary embolism after a recent subdural hematoma. 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD.  
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in this case the enrollee is not 
readily suspected of either having AD or FTD. Rather the notes indicate that the provider is evaluation for 
Dementia with Lewy Bodies (DLB) or a Parkinson's plus syndrome. These latter two indications are not ones 
for which the applicable NCD supports the use of PET/CT of the brain. In as much it can be said that the 
enrollee does not meet the coverage criteria detailed in the NCD. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group3 power wheelchair with a single power option 
(K0856), power tilt (E1002), expandable controller (E2377, E2311, E2313), and accessories (E2361, E1028, 
E0955, E1012, E0956, E2605, E2615, E0952).  
You asked the Plan to pre-approve a group3 power wheelchair with a single power option, power tilt, 
expandable controller, and accessories. You say that this is medically necessary. The Plan denied your request. 
The Plan says you do not need the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with a single power 
option will be covered if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or 
congenital skeletal deformity; and either the beneficiary meets coverage criteria for a power tilt and recline 
seating system and the system is being used on the wheelchair or the beneficiary requires a drive control 
interface other than a hand or chin-operated standard proportional joystick. 
 
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 group3 power wheelchair with a 
single power option, power tilt, expandable controller, and accessories. Our reviewer says that the requested 
wheelchair is not medically necessary. Our physician reviewer found the provided records do not support that 
you are at high risk for skin breakdown, have a history of pressure ulcers, or have had skin flap surgery. The 
records document you can walk a few steps with a walker and are able to safely transfer in and out of your 
wheelchair. The records do not document that you perform bladder self-catheterization or that you have 
increased muscle tone or spasticity. 
 
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 group3 power wheelchair with a single power option, power tilt, expandable 
controller, and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a group3 power wheelchair with a single power option (K0856), power tilt (E1002), expandable controller 
(E2377, E2311, E2313), and accessories (E2361, E1028, E0955, E1012, E0956, E2605, E2615, E0952).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided on February 23, 2022, to February 
24, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for inpatient care provided on 
February 23, 2022, to February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography cerebral perfusion analysis (CTP) 
provided to the enrollee on June 16, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not reported with an approved diagnosis. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had computed tomography and angiography (CT/CTA) of the brain followed by CT 
perfusion on 6/16/22. The rules state that CTP may only be used when there is large vessel occlusion within 3 
hours of acute event and intervention is contemplated. In this particular case the CT and CTA reports done on 
6/16/22 have not been enclosed and as such it cannot be determined if the criteria necessary for approving CTP 
have been met. Additionally, in the letter of appeal from the physician on 7/4/22, the appeal relates to an issue 
not present in the case. The appeal letter concerns a low dose computed tomography (LDCT) for lung cancer 
screening which is not applicable for this particular case. It's quite possible that the incorrect code has been 
submitted. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a computed tomography cerebral perfusion analysis (CTP) provided to the enrollee on June 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the cost sharing amounts for the outpatient services provided 
from September 3, 2020, to March 30, 2021. 
 
You asked the Plan waive the cost sharing amounts for the outpatient services. You say that you cannot afford 
to pay this bill. The Plan denied your request. The Plan says the cost sharing amounts were charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Physician or Practitioner Services.  
 
You have been asked to pay a $35 copayment for each specialist visit in 2021, a $40 copayment for each 
specialist visit in 2020 these services fall within the Physician or Practitioner Services benefit category. You 
have been asked to pay a $10 copayment for each covered laboratory service in 2020 and 2021. These services 
fall within the Outpatient Diagnostic Tests and Therapeutic Visits and Supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have waive the cost sharing amounts for the outpatient services provided from September 3, 2020, to 
March 30, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the subsequent nursing facility care, per day (99308, 
99309, 99310) provided from June 30, 2022, through July 15, 2022. 
 
You asked the Plan to waive the cost share for these services. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says that the cost share has been 
applied correctly to these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided evidence that the yearly deductible has 
been met in this case. Additionally, an original claim nor the medical records have been included in the case 
file to confirm that the indicated services have been provided. Therefore, we decided that the Plan has to waive 
the cost share for the subsequent nursing facility care, per day (99308, 99309, 99310) provided from June 30, 
2022, through July 15, 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: 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 a urinary tract infection and a cholecystectomy for 
cholecystitis. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
June 3, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 
3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a dermatology visit provided on August 
23, 2022. 
 
You asked the Plan to reduce the copayment for a dermatology visit. You say that the copay on your card says 
$20, not $25. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for a dermatology visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for a dermatology visit provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory (electronic connection - 
E2311). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be able to 
control the power options using their own switches which are included in the allowance of these 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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records document that the enrollee has 4/5 left upper extremity strength and 4-/5 right 
wrist strength and wrist/hand reported as "WFL" thus indicating he has adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches.  
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power wheelchair accessory (electronic connection - E2311).
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 the enrollee was admitted for sepsis and abscess of the hand. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on May 27, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment provided on May 27, 2022.