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

 
We decided that the Plan does not have to pre-approve avelumab (Bavencio). 
 
You asked the Plan to pre-approve avelumab. You say that the enrollee has a diagnosis of small cell 
neuroendocrine tumor of the bile ducts. You also say that for this type of disease, the treatment paradigm 
follows the guideline for small cell lung cancer. The Plan denied your request. The Plan says the requested 
drug is not approved by the Food and Drug Administration (FDA) or listed in the Medicare approved sources. 
 
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 avelumab. Our reviewer says that the 
requested use of avelumab is not medically necessary. Our physician reviewer found the requested use of avelumab is not approved by the Food and Drug Administration (FDA) for the enrollees diagnosis. The 
reviewer also found that the use is not supported by one of the major drug compendia or by clinical research 
that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of 
avelumab is not medically reasonable or necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of avelumab have not been met. Therefore, we decided that the Plan does not have 
to pre-approve avelumab (Bavencio).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve six office visits. You say that you would like your surgery sooner then when 
in-network providers can schedule it. The Plan denied your request. The Plan says there are in-network 
providers that can perform this service. 
 
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 
six office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you need this device due to your COPD. 
The device is needed while sleeping and sometimes throughout the day. The Plan denied your request. The 
Plan says records do not show you have failed treatment with positive airway pressure. The request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic respiratory failure from chronic obstructive pulmonary disease and obesity. The provided primary 
source documentation is insufficient and does not contain sufficient detailed information in the medical record 
to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. The plan 
has indicated coverage for such a device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, full leg segmental pneumatic appliance, and a 
trunk segmental pneumatic appliance. 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 pneumatic compression devices are covered when 
specific 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 a pneumatic compressor, full leg 
segmental pneumatic appliance, and a trunk segmental pneumatic appliance. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the segmental calibrated gradient pressure pneumatic compression device 
(E0652) and associated appliances at issue in this case meet all Medicare criteria for medically reasonable and 
necessary for you. Provided records in this case do not document you have tried and failed at least four weeks 
of regular, daily, multiple-hour home usage of a basic pump (E0650 or E0651) after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. 
 
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 pneumatic compressor, full leg segmental pneumatic appliance, and a trunk 
segmental pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic compressor, 
full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Kit continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Kit CGM sensor. You say that the enrollee is a newly diagnosed 
diabetic and currently testing two times per day. The enrollee needs this CGM to see his blood sugar in real 
time. Using the CGM has helped the enrollee better control his BG, and there is a chance he may be able to get 
the A1C to goal. The Plan denied your request. The Plan says a CGM is not covered under Medicare if the 
enrollee is not on insulin or does not have documentation of history of problematic hypoglycemia. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections or require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Kit CGM sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Kit continuous glucose monitor (CGM) sensor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need more time to complete strengthening in 
your back and legs. The Plan denied your request. The Plan says your request for a continued SNF stay is 
denied as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is extremely weak. They require IRF 
services in order to rebuild strength and return to their baseline. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to care for yourself and require 
around the clock rehabilitation and care. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two more home health skilled nursing visit effective 
from March 30, 2023, to May 28, 2023. 
 
You asked the Plan to pre-approve home health services. You say that additional home health skilled nursing 
visits are medically necessary for the enrollee. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The requested, ongoing, home health skilled nursing services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two more home health skilled nursing visit effective from March 30, 2023, to 
May 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, heavy-duty, wheeled, rigid or folding (E0149) 
and a seat attachment (E0156). 
 
You asked the Plan to pre-approve a heavy-duty walker and seat attachment. You say that you need the 
requested heavy-duty walker and cannot wait any longer. The Plan denied your request. The Plan says you do 
not meet the established criteria for a heavy-duty walker. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries 
who meet coverage criteria for a standard walker and who weigh more than 300 pounds.  
 
 
 
 
 
 
 
 
  
We looked at the file and Medicare rules. The records show you do not weigh 300 pounds or more, therefore, 
you do not meet criteria for approval of the requested walker. Medicare rules say you must weigh more than 
300 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker 
and seat attachment have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
walker, heavy-duty, wheeled, rigid or folding (E0149) and a seat attachment (E0156).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure (LAAC). 
 
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 LAAC is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has an elevated risk of 
thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. There is no documented 
contraindication to anticoagulation. The criteria for coverage are not met and the LAAC is not reasonable or 
medically necessary for the enrollee at this time. 
 
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 left atrial appendage closure (LAAC).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Gemcitabine, Carboplatin, and 
Dexamethasone. 
 
You asked the Plan to pre-approve Keytruda, Gemcitabine, Carboplatin, and Dexamethasone. 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, Gemcitabine, Carboplatin, 
and Dexamethasone. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found provided medical records, guidelines of the National Comprehensive Cancer Network and the Medicare-
approved major drug compendia do not support that the regimen of Ketruda (J9271) Gemcitabine (J9201), 
Carboplatin (J9045) and Dexamethasone (J8540) is safe and effective without knowing the programmed cell 
death ligand 1 status of your tumor. 
 
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, Gemcitabine, Carboplatin, and Dexamethasone have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Keytruda, Gemcitabine, Carboplatin, and 
Dexamethasone.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. 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. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have not tried and failed the required 
drugs. There is no documentation provided indicating that the plans required drugs would likely be less 
effective and/or likely have adverse effects for the you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed. 
 
You asked the Plan to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed. 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 Carboplatin, Pembrolizumab, and 
Pemetrexed. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the medical records provided, guidelines of the National Comprehensive Cancer Network and the 
Medicare-approved major drug compendia there is no documentation that the carboplatin, pembrolizumab and 
pemetrexed regimen at issue in this case meets all Medicare criteria for safe and effective for the enrollee. The 
requested regimen is not supported as second line therapy for metastatic adenocarcinoma of the lung with a 
history of prior treatment with carboplatin/Taxol/Abraxane and later disease progression on nivolumab. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin, Pembrolizumab, and Pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, and Pemetrexed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve a lumbar facet RFA. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 
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 lumbar facet RFA. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is lack of information in the 
provided documentation, including operative reports for two diagnostic medial branch blocks with at least 80% 
pain relief consistent with medication used. There is no documentation of the duration or percentage of pain 
relief from the right L3-S1 RFA. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
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 lumbar facet RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar facet radiofrequency ablation (RFA).