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

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the available literature does not appear to satisfy the off-label policy. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found you have a rare disease 
with no guidelines for treatment. Literature is largely case reports with several showing significant response in 
elderly patients with the use of Keytruda/Pembrolizumab.  
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show results of prior imaging that show a reason why this request is 
needed. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee's pathology 
showed a typical endobronchial carcinoid tumor, which was treated surgically in November 2020. Surveillance 
CT exams in May and November 2021 showed no sign o metastasis or tumor recurrence. The enrollee has no 
clinical symptoms to suggest tumor recurrence. The guidelines allow for annual CT up to two years after 
surgical removal of such a tumor, and then every two years. The medical records do not show an indication for 
the 6 month surveillance requested with the tumor which had been removed surgically in November 2020. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve the requested device. You say that the technology is appropriate for 
neurological arm weakness. The Plan denied your request. The Plan says Medicare does not cover experimental 
services. 
 
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 requested device. Our physician 
reviewer found that in this case, the requested device is used for the upper extremity. It is an arm brace that is 
motorized and can help an individual with upper extremity weakness to move their arm and hand. The device 
has not been shown to be superior to other standard treatments for the enrollees medical condition. The studies 
do not indicate the MyoPro brace improves an individuals function or general health. Therefore, the requested 
device is not medically necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthotic device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumakras 120 mg tablet. 
 
You asked the Plan to pre-approve Lumakras. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
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 Lumakras 120 mg tablet.  
 
Benefits for Lumakras 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve facet joint RFAs. You say that the enrollee had relief from diagnostic blocks 
and would benefit from radiofrequency ablation. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the enrollee has only had one set of diagnostic medial branch 
blocks and needs a second confirmatory set. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint radiofrequency ablation is only covered if 
certain criteria are 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 facet joint RFAs. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint RFAs. Our physician reviewer 
found in order for facet joint radiofrequency ablations to be approved, the enrollee must have had at least 2 
diagnostic medial branch blocks (MBBs) with each one providing a consistent minimum of 80% sustained 
relief of primary pain. However, the record states that the enrollee has had only one diagnostic injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint RFAs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint radiofrequency ablations (RFAs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
resin-based composite - three surfaces, anterior (D2332) provided December 14, 2021. 
 
You asked the Plan to pay for the limited oral exam and filling. You say that you have no knowledge of 
benefits paid out during the coverage period. The Plan denied your request. The Plan says you have exhausted 
your dental allowance for 2021. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam and filling up to the $1,500 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the full $1,500 dental 
allowance has been applied to dental services received in 2021. Based on this information, we decided that 
your dental allowance has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) and resin-based composite - three surfaces, anterior (D2332) 
provided December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that non-invasive ventilator therapy is much more 
appropriate for the severity of the enrollee's condition and without it the enrollee will likely continue to have 
exacerbation or hospitalizations. The Plan denied your request. The Plan says the denial of authorization for 
this device is correct, because there is no compelling rationale to support a ventilator instead of a bi-level 
positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS) mode. 
 
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 the 
enrollee does not meet the Medicare criteria for the requested ventilator. Our physician reviewer found the 
enrollee has chronic obstructive pulmonary disorder (COPD) and obesity hypoventilation syndrome.  The enrollee may benefit from bi-level positive airway pressure (BiPAP) therapy during sleep, but there is no 
evidence that BiPAP has been tried and failed. Average volume-assured pressure support (AVAPS) mode can 
be provided via BiPAP. Medicare does not cover a home ventilator when used as a BiPAP. 
 
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 a home portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on July 18, 2020. 
  You asked the Plan to pay for the emergency room services. You say that you are registered with Medicare and 
the claim needs to be reprocessed. The Plan denied your request. The Plan says CPT code 99070 is not 
recognized by the Outpatient Prospective Payment System (OPPS). 
 
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 code the emergency room services are not supported in the medical record. Specifically, CPT 
code 99070 billed on this claim has a status indicator of B. This means that the code is not recognized by OPPS 
and not payable when billed on an outpatient claim. Based on this information, we decided that Medicare rules 
for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency room services provided on July 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 services to be performed by a qualified physical 
therapist in the home health setting (G0151 x8). 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
the medical record does not document a clearly evident need for the services of a skilled physical therapist. 
 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 physical therapy services. Our 
reviewer says that the requested, ongoing, home health physical therapy services are not medically necessary or 
reasonable. Our physician reviewer found the enrollee does not have documented, ongoing, skilled physical 
therapy needs. Our reviewer also found that the enrollee is functioning at a level commiserate with a lower 
level of 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 the physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 services to be performed by a qualified physical therapist in the home 
health setting (G0151 x8).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in a different setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee has a past medical history of COVID-19 with prolonged hospitalization, and is living at home 
receiving services from hospice. There is progressive weakness. 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 this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate specific antigen (PSA) testing rendered on 
October 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you exceeded the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PSA screening is covered once every 12 months. 
 We looked at the file and Medicare rules. The file shows that you had a PSA screening on June 4, 2021 that the 
Plan covered. The PSA screening on October 27, 2021 was performed less than 12 months from your 
previously covered screening. Therefore, we decided that the Plan does not have to pay for the prostate specific 
antigen (PSA) testing rendered on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you are in need of a hospital 
bed. You also say that you recently had back surgery and cannot do anything on your own. The Plan denied 
your request. The Plan says the rules have not been met for the approval of a semi-electric hospital bed. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that you do not meet the criteria for coverage of a semi-electric hospital bed. Our physician 
reviewer found that the documentation does not reveal a frequent or immediate need for a change in body 
position, therefore this request is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee needs continued 
treatments and care that can only be given in a hospital 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. The enrollee 
was admitted with hypoxic respiratory failure due to pneumonia. The record indicates that the enrollee is 
improving but still requires ongoing acute care services. The enrollee continues to receive acute care services, 
and these have not been denied. The medical record does not indicate that the enrollee requires services that she 
is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary, as you are currently using 
a cane to get around, but not able to navigate easily. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 based on the medical records provided there is no documentation that the requested crutch 
substitute/knee scooter at issue in this case meets Medicare criteria for being medically reasonable and 
necessary. A crutch substitute/knee scooter has not been shown to be a safe and effective device in the 
Medicare population as required by Social Security Act, Section 1862(a)1(A). 
 
 
 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 knee scooter/crutch substitute.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck/soft 
tissue. 
 
You asked the Plan to pre-approve the CT scan. You say that you are choking when you lay in a certain 
position and this has gotten worse over the last 6 months. You said that you fear as though this might be cancer. 
The Plan denied your request. The Plan says you should undergo an ultrasound first, and there are no records 
showing that you have trouble swallowing. 
 
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 CT scan. Our reviewer says that a 
CT scan is not medically necessary at this time. Our physician reviewer found the medical records show no 
evidence of swallowing difficulty. You had a cursory physical exam of the neck that was unremarkable and 
there is no evidence of an otolaryngology consultation.  
 
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 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 neck/soft tissue.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on September 13, 2021.