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

 
We decided that the Plan does not have to pre-approve Gemcitabine (J9201) to be used in combination with 
Docetaxel (J9171). 
 
You asked the Plan to pre-approve Gemcitabine to be used in combination with Docetaxel. The Plan denied 
your request. The Plan says the approach and requested regimen remain experimental/investigational in this 
setting. 
 
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 Gemcitabine to be used in combination 
with Docetaxel. Our reviewer says that Gemcitabine to be used in combination with Docetaxel is not 
reasonable and necessary. Our physician reviewer found the requested use of Gemcitabine to be used in 
combination with Docetaxel is not FDA-approved for the enrollees diagnosis. Our reviewer found that the use 
is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the 
use of Gemcitabine to be used in combination with Docetaxel is not listed as not indicated, not supported or not 
recommended in any of the compendia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine to be used in combination with Docetaxel have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Gemcitabine (J9201) to be used in 
combination with Docetaxel (J9171).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
11, 2022, to May 11, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the billed 
date of service April 11, 2022, to May 11, 2022 is more than the 30-day episode that should be billed. This 
claim is not payable as billed. Therefore, we decided that the Plan does not have to pay for the home health 
services provided to the enrollee from April 11, 2022, to May 11, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on June 21, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that this claim was billed with a date 
of service inconsistent with Medicare rules governing laboratory services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The case file does not show that the lab service does not meet any of the exceptions outlined in the Medicare 
ruling. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request. Therefore, we decided that the Plan has to pay for the genetic testing 
services provided on June 21, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical arthroscopy (procedure code 29823) provided to the enrollee 
on March 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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, the CPT Code Manual definition of 
code 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee was being treated for 
right shoulder symptomatic AC (acromioclavicular) arthritis, impingement, anterior superior labral tearing, 
synovitis, partial tearing of the supraspinatus, and mild synovitis. She underwent an arthroscopic distal clavicle; 
arthroscopic debridement of anterior superior labral tear, partial tear of the rotator cuff involving about 10% of 
the supraspinatus insertion, and synovitis; arthroscopic subacromial decompression on 3/22/22. The procedure 
report details cite the arthroscope was placed in the humeral joint and tearing of the anterior and superior 
labrum. This was debrided back to stable tissue. There was synovitis that was debrided in the anterior capsule. 
Partial tearing of the supraspinatus involving about 10% of the tendon width was debrided back to stable 
tissue. Therefore, the records do support CPT 29823 in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical arthroscopy (procedure code 29823) provided to the enrollee on March 22, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve am-trastuzumab deruxtecan-nxki (also called Enhertu) 
(CPT code J9358). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the use of Enhertu for endometrial cancer is not FDA approved 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 the medication. Our physician reviewer 
found the requested use of am-trastuzumab deruxtecan-nxki (also called Enhertu) is not FDA-approved for the 
enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that 
appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve am-trastuzumab deruxtecan-nxki (also called Enhertu) (CPT code J9358).
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 strongly urge the denial to be 
reconsidered. You also say without non-invasive ventilator (NIV) therapy, the enrollee is at high risk for 
hospital readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan 
says the request for an NIV 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 a home ventilator is not medically necessary. Our physician reviewer found this enrollee has a diagnosis of 
COPD, although the records do not include pulmonary function test results. The enrollee was hospitalized in 
September after a fall, with fractured ribs, lung contusion, pneumonia, and exacerbation of COPD. Our 
reviewer found initial arterial blood gases (ABGs) were consistent with acute on chronic hypercarbic 
respiratory failure. But a subsequent ABG result mentioned in the progress notes shows normal potential of 
hydrogen (pH) and partial pressure of carbon dioxide (PaCO2). There is no documentation of chronic carbon 
dioxide (CO2) retention. Our physician review found it seems likely that the enrollee's hypoventilation on 
admission was in part related to the acute pulmonary insults that have now improved. If the enrollee does have 
chronic CO2 retention, documented on an ABG done while stable, the enrollee may benefit from bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support. Our reviewer also found that 
Medicare does not cover a home ventilator when used as 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided May 26, 
2022, to May 29, 2022. We also decided that the Plan does not have to waive the copayment for inpatient 
mental health care provided from May 29, 2022, to June 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care and inpatient mental health care. You 
say that you are appealing the cost share applied to these services. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that for in-network, 
inpatient hospital care you must pay a $315 copayment per day for days 1 to 5, and $0 copayment per day for 
days 6 to 90, and $0 copayment for days 91 and beyond. 
 
Your contract with the Plan also says for in-network, inpatient mental health care you must pay a $295 
copayment per day for days 1 to 5 and $0 copayment per day for days 6 to 90.  
 
You have been asked to pay $945 ($315/day x 3 days =$945) for inpatient hospital care. You have also been 
asked to pay $1,180 ($295/day x 4 = $1,180) for inpatient mental health care. The total you owe is $2,125 
($1,180 + $945 = $2,125). The inpatient hospital care falls within the inpatient hospital care benefit category. 
The inpatient mental health care falls within the inpatient mental health care 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 inpatient hospital care provided May 26, 2022, to May 29, 2022, or 
for the inpatient mental health care provided from May 29, 2022, to June 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on April 27, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
services provided on April 27, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the cost share for a therapeutic injection and a darbepoetin injection. 
 
You asked the Plan to waive the cost share for the injections. You say that you should not be responsible to pay 
this. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
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 failed to provide the Explanation of Benefits (EOB) for these dates of 
service. Without an EOB, we are unable to confirm the cost share was applied correctly. Therefore, we decided 
that the Plan has to waive the cost share for the injections.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging single-photon emission 
computerized tomography (SPECT) test (78452). 
 You asked the Plan to pre-approve a myocardial perfusion imaging SPECT test. You say that you have ordered 
this nuclear stress test because the enrollee would benefit from further risk stratification. The Plan denied your 
request. The Plan says this request is not medically necessary because the medical record does not support new, 
recurrent, or worsening cardiac symptoms. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 myocardial perfusion imaging SPECT 
test. Our reviewer says that a myocardial perfusion imaging SPECT test is not reasonable and necessary. Our 
physician reviewer found there is no history of chest pains, shortness of breath, or palpitations. There is no 
documentation that the electrocardiogram (ECG) shows an uninterpretable pattern. Our reviewer found there is 
no evidence provided that would support the need for radionuclide stress testing. Our physician reviewer also 
found in summary, there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in this enrollees clinical management. 
 
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 myocardial perfusion imaging SPECT test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a myocardial perfusion imaging single-photon emission 
computerized tomography (SPECT) test (78452).
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. You say that the enrollee needs long term care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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. Our 
physician reviewer found the enrollee appears to be somewhat unstable at this time but should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
for transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to the LTACH is not medically necessary as the patient is currently unstable and as it would 
not be clinically advantageous at this time. Completion of treatment at the current facility is 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 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: 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 appealing with supporting records. 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 enrollee does have active comorbidities that would benefit from close 
medical supervision however there are no documented complex functional deficits. The enrollee was not 
receiving therapy in home health setting, they are oxygen dependent and receiving five hours of home health 
aide per day at baseline. IRF criteria are not met. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand of diabetic testing supplies. 
 
You asked the Plan to pre-approve a non-preferred brand. The Plan denied your request. The Plan says the 
requested system is not one of the preferred systems. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that plans may specify brands and manufacturers as preferred.  
 
 
 The requested brand of supplies is not a preferred brand. The Plan has brands available who can provide the 
items at issue in this appeal. We found no exception that would require the Plan to pre-approve these non-
preferred items. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand of 
diabetic testing supplies.
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 are at risk for falling. The Plan denied your 
request. The Plan says you do not need three hours of therapy a day. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical 
problems are stable.  While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation 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 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.