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

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee did not meet the Plan's required step therapy criteria. 
 
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 Simponi Aria. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
Plan's required step therapy drugs and the documentation does not support that the required drugs would likely 
be less effective than the requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care from April 12, 2022, 
forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that inpatient 
mental health care continues to be medically necessary. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient mental 
health care. Our reviewer says that the requested continuation of inpatient mental health care is not medically 
reasonable and necessary. Our physician reviewer found this 63-year-old male was admitted to the acute 
inpatient psychiatric hospitalization on February 21, 2022, with Paranoid Schizophrenia. Based upon review 
the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others. He had a reduction in auditory no 
visual hallucinations and was without aggressive behaviors while not showing any acute threats of safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal 
thoughts with a reduction in auditory no visual hallucinations or abnormal behaviors. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient mental health care from April 12, 2022, 
forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel Mini injection cartridges. 
 
You asked the Plan to pre-approve the Enbrel Mini injection cartridges. You say that this drug is medically 
necessary to treat the enrollee's condition. The Plan denied your request. The Plan says this is a self-injected 
medication that is not 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 Enbrel Mini injection cartridges.  
 
Benefits for the Enbrel Mini injection cartridges 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable connect adaptive rehab device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says exercise 
equipment is non-covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a portable connect adaptive 
rehab device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debridement of subcutaneous tissue 
(11042) and a duplex scan of lower extremity arteries or arterial bypass grafts (93926) provided from 
September 13, 2021, to October 25, 2021. 
 
 
 
 You asked the Plan to waive the copayment for debridement of subcutaneous tissue and a duplex scan of lower 
extremity arteries or arterial bypass grafts. You say that you are being charged for four outpatient surgery 
copayments in three weeks (October 4, 2021, to October 25, 2021) for cleaning off a scab on a small leg wound 
(weekly visit to hospital wound center). You also say you were charged 3 times in September for $675 
(September 13, 2021, to September 27, 2021). The Plan denied your request. The Plan says you were 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. Your contract with the 
Plan also says that enrollees must pay a $85 copayment for Medicare-covered radiological diagnostic services, 
not including x-rays, performed in a physicians office or at a free-standing facility (such as a radiology center 
or medical clinic). The diagnostic radiology services require specialized equipment beyond standard x-ray 
equipment and must be performed by specially trained or certified personnel, which includes ultrasounds.  
 
You have been asked to pay a total of $1,775 in copayments for the debridement of subcutaneous tissue on six 
separate visits ($295 copayment x 6 visits = $1,775). The debridement of subcutaneous tissue falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. You also have been asked to pay an $85 copayment for a duplex scan of lower 
extremity arteries or arterial bypass grafts. A duplex scan of lower extremity arteries or arterial bypass grafts 
falls under the outpatient diagnostic tests and therapeutic services 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 to waive the copayment for debridement of subcutaneous tissue (11042) and a duplex scan of 
lower extremity arteries or arterial bypass grafts (93926) provided from September 13, 2021, to October 25, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a bi-level positive airway pressure (BiPAP) device 
is unsuitable for you because your diagnosis is too severe. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because a ventilator is not covered when used to provide 
positive airway pressure therapy and you can be treated by a BiPAP instead. 
 
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 ventilator. Our reviewer says that you 
do not meet the Medicare criteria for use of a ventilator. Our physician reviewer found you have chronic 
respiratory failure from chronic obstructive pulmonary disorder (COPD). The record does not contain sufficient 
detailed information to justify a ventilator.  You could be treated by a bi-level positive airway pressure (BiPAP) machine with average volume assure 
pressure support (AVAPS) capability, which the Plan has indicated would be approved upon request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and Doxorubicin. 
 
You asked the Plan to pre-approve Keytruda and Doxorubicin. You say that these drugs are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of 
these drugs have not been satisfied. 
 
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 and Doxorubicin. Our 
reviewer says that the requested drugs are not medically reasonable and necessary. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of metastatic Triple Negative Breast Cancer.  The 
Food and Drug Administration has not stated that the requested drug regimen 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 regimen 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 and Doxorubicin have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Keytruda and Doxorubicin.
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 you have had a severe decline in function following 
acute hospitalization and not going to an IRF puts you at risk for further medical complications and 
deterioration. The Plan denied your request. The Plan says IRF care is not medically necessary and you can be 
managed at a lower 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 you were admitted for myocardial infarction and your medical problems are stable. 
You have 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 24, 2020, 
to July 1, 2020, billed with diagnosis related group (DRG) code 854. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 854.. You say that A41.9 (Sepsis, 
unspecified organism) was appropriately coded as the principal diagnosis for this case, and the DRG should 
remain 854, infectious and parasitic diseases with O.R. procedure with CC. The Plan denied your request. The 
Plan says DRG 854 is not supported as the diagnosis of Sepsis, unspecified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, 
unspecified. 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 inpatient hospital services billed 
with DRG 854. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the 
medical records did not support the billing of Sepsis, unspecified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from June 24, 2020, to July 1, 2020, billed with diagnosis related 
group (DRG) code 854.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab services provided on September 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Lab services. You say that services are medically necessary for continuation of 
care. The Plan denied your request. The Plan says the rendering provider is non-par and there isnt a referring 
provider. 
 
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 Lab services provided on September 22, 2021 by 
an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says the 
enrollee has not completed the full course in the hospital. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital for right ankle and foot osteomyelitis. 
Her hospital course was complicated by hypercapnic respiratory failure.  The enrollee is receiving appropriate 
care at the present acute care hospital. She does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that 
she requires that are not available at the health care setting being offered by the health plan. Therefore, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for a Zoll LifeVest provided from October 2, 2021, to 
November 2, 2021. 
 
You asked the Plan to waive the coinsurance for a Zoll LifeVest. You say that you only used the vest for a 
month, and it was returned as soon as the month was over. You also say that you should not be charged for 
additional months you did not have or use the device. The Plan denied your request. The Plan says that you 
have been charged the correct cost sharing amount. 
 
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. The Plan did not provide records to confirm when the Zoll LifeVest was 
received and returned. Without the records we are unable to determine if the cost sharing applied is correct. 
Therefore, we decided that the Plan has to waive the coinsurance for a Zoll LifeVest provided from October 2, 
2021, to November 2, 2021.  
 
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 waive the copayments for x-rays of both the left and right ankles 
provided on December 15, 2021. 
 
You asked the Plan to waive the copayments for x-rays of both ankles. You say that you were unaware that you 
would have a copayment for each x-ray received if they were done on the same day. You also say these 
copayments were in addition to a spinal x-ray done on the same day. 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 $50 
copayment for each in-network standard x-ray.  
 
 The record shows the claims were processed correctly. You have been asked to pay the allowed amount of 
$32.18, which is less than the $50 copayment for each ankle x-ray. Ankle x-rays fall within the Outpatient 
Diagnostic Tests and Therapeutic Services 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 to waive 
the copayments for x-rays of both the left and right ankles provided on December 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myocardial perfusion imaging, tomographic (SPECT) 
(78452) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SPECT. You say that you disagree with the denial and wan the Plan to 
reconsider. The Plan denied your request. The Plan says this service is not covered with an out-of-network 
provider. 
 
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 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 
Myocardial perfusion imaging, tomographic (SPECT) (78452) to be provided by an out-of-network (OON) 
provider.