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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found 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. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the unspecified item coded as A9270-GA provided along 
with an ankle-foot orthosis (AFO) on February 8, 2022. 
 
You asked the Plan to hold you harmless for the unspecified item coded as A9270-GA. You say that you were 
told that you need this brace in order to walk. The Plan denied your request. The Plan says that supportive 
shoes and inserts are not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the unspecified item coded as A9270-GA by a contract provider. This item was billed 
with a modifier -GA which means that the provider informed you it would not be covered and that you signed 
to agree to purchase the item anyway. The Plan has provided no evidence regarding what this item is nor that 
you were informed of non-coverage. Under Medicare rules, this means the unspecified item coded as A9270-
GA is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the 
unspecified item coded as A9270-GA provided along with an ankle-foot orthosis (AFO) on February 8, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head. 
 
You asked the Plan to pre-approve the requested head CT scan. You say that this is necessary to evaluate for 
dementia. The Plan denied your request. The Plan says the objective findings during the examination do not 
support the need for CT imaging of the head. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested head CT scan. Our 
reviewer says that the requested imaging is not considered reasonable and necessary. Our physician reviewer 
found there is no documentation that the requested CT scan meets Medicare criteria for medically reasonable 
and necessary. Provided records do not document objective evidence of dementia or another diagnosis which 
would meet Medicare criteria for a head CT scan. Records report a normal score on a Saint Louis University 
Mental Status (SLUMS) Examination and her neurological testing and psychiatric exam were reported as 
normal.  
 
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 requested head CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the head.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan 
provided on January 15, 2022, billed with code 70450. 
 
You asked the Plan to pay for the CT interpretation as billed. You say that this should be paid as multiple 
images were taken. The Plan denied your request. The Plan says a required modifier is not billed in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan 
provided on January 15, 2022, billed with code 70450.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve Retacrit. You say that Retacrit is medically necessary. The Plan denied your 
request. The Plan says that the drug is not being used under the medically-accepted standard. 
 
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 Retacrit. Our reviewer says that 
Retacrit is medically reasonable and necessary. The documentation indicates that the patient's transferrin 
saturation is not at least 20% or the ferritin is not at least 100ng/mL. The review has determined that the 
requested use of Retacrit FDA-approved for the enrollees diagnosis. Its use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (T2005, A0380) provided on September 23, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes T2005 and A0380 have a Status Indicator of I on the Physician Fee Schedule. This 
means that CPT codes T2005 and A0380 are not valid for Medicare purposes. 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 the services (T2005, A0380) provided on September 23, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you would be better served in a slower paced, less intensive rehab 
program. 
 
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. You are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute nursing needs identified or documented. You do not require 3 hours a day five 
days a week of IRF therapies with interdisciplinary management. The lack of complexity of your medical 
condition and lack of nursing needs do not support an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitation care. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
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. You say that this request cannot be approved because she does not 
need three hours a day of therapy and her medical illnesses are stable, and she does not need a physician to 
monitor them three times a week. The Plan denied your request. The Plan says that the enrollee needs IRF care 
to recover from fractures. 
 
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 that multiple fractures/trauma is an IRF compliant diagnosis. Clinical documentation demonstrates that 
this enrollee has complex functional impairments and a history of a connective tissue disorder with medical 
comorbidities that would warrant close medical monitoring in an inpatient stay with an interdisciplinary 
approach to rehabilitation care. Evaluating therapists recommend intense rehabilitation and the enrollee is 
being followed by multiple disciplines of therapy. Overall, plan of care document gives a reasonable 
expectation that the enrollee will be able to tolerate from and significantly benefit from intense rehabilitation 
program 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 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
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 the enrollee has not had a recent trial of 
physical therapy documented in the submitted records. More conservative measures are needed prior to 
surgery. 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 total knee arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi and Carboplatin. 
 
You asked the Plan to pre-approve Mvasi and Carboplatin. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Mvasi and Carboplatin. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found 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. 
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 Mvasi and Carboplatin have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Mvasi and Carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received from September 13, 
2021, to November 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services you received from September 13, 2021, to 
November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral formula, nutritionally complete with intact 
nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered 
through an enteral feeding tube (B4150). 
 
You asked the Plan to pre-approve the enteral formula. You say that the enrollee previously required 
supplemental enteral nutrition in the form of protein shakes to maintain a healthy weight. The enrollee has lost 
close to 12 pounds in the 2 months that she has not been drinking her protein shake supplements. The Plan 
denied your request. The Plan says the enrollee does not have an enteral access device (feeding tube) and 
therefore does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that enteral nutrition is covered for a beneficiary who 
requires feedings via an enteral access device. 
 
We looked at the file and the Medicare rules. The records show that the enrollee does not have a feeding tube 
and is looking for an oral shake supplement to maintain weight. The rules say that Medicare does not pay for 
nutritional supplementation. Although these may be appropriate, neither Medicare nor the Plan provides 
coverage for them. Therefore, we decided that the Plan does not have to pre-approve the enteral formula, 
nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may 
include fiber, administered through an enteral feeding tube (B4150).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G1004) provided on November 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code G1004 is not supported in the medical record. Specifically, code G1004 
returns OCE edit 112 which means that this code is non-covered and payment cannot be made. 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 the services (G1004) provided on November 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 5, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the nursing home is responsible to 
obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
28, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that ambulance services should be 
covered in full, and that you cannot afford this cost share, The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $350 
copayment for ambulance services.  
 
You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the 
Ambulance Services 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 waive the copayment for ambulance services 
provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the requested services is not supported in the medical record. Specifically, the claim 
was returned with OCE edit 62. This edit returns the entire claim to the provider and no payment can be made. 
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 the services provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management (EM) services 
provided on January 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON telephone EM services. You say that this was a medically necessary 
EM service. The Plan denied your request. The Plan says this is not covered when provided OON without 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management (EM) 
services provided on January 27, 2022 by an out-of-network (OON) provider.