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

 
We decided that the Plan does not have to pre-approve Cosentyx auto-injector. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has failed other 
medications. The Plan denied your request. The Plan says this drug 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 Cosentyx auto-injector.  
 
Benefits for self-administered drug 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 Intensity modulated radiation therapy. 
 
You asked the Plan to pre-approve the Intensity modulated radiation therapy. You say that this service is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Intensity modulated radiation 
therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no justification for Intensity modulated radiation therapy in the 
records 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 the Intensity modulated radiation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Intensity modulated radiation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab). 
 
You asked the Plan to pre-approve Keytruda. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has triple neg cT2N+ breast cancer. The enrollee refuses chemotherapy. The 
requested drug is not Food and Drug Administration (FDA) approved as a monotherapy for the enrollee's 
diagnosis. The requested use of this drug is not supported in one one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria 
for the requested drug. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (pembrolizumab).
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 rehab would help you as it has in the past. The Plan 
denied your request. The Plan says you can receive your care in another setting, such as a skilled nursing 
facility. 
 
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 do not require treatment by multiple therapies. You do not require intensive 
rehabilitation or frequent physiatry oversight. The criteria for an inpatient rehab facility stay is 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid Doppler examination (93880). 
 
You asked the Plan to pre-approve a carotid Doppler examination. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a carotid Doppler examination. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of a bruit on physical examination of the 
asymptomatic 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 a carotid Doppler examination have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a carotid Doppler examination (93880).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service September 18, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the code is 
included in procedure code 99285 for the same day. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that payment for CPT code 99223 is supported. Initial inpatient care is payable if the enrollee is 
admitted from the emergency room. Furthermore, the Plan has not provided documentation to show that an 
emergency room code was billed by the same provider/group for the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for procedure code 99223 billed for date of service September 18, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you need to 
walk again, and you need the requested device for health problems, to avoid having to undergo surgery. The 
Plan denied your request. The Plan says your records do not show objective evidence of truncal edema. They 
do not show that you have undergone a 4-week trial of conservative management which includes the use of a 
E0650 or E0651 pneumatic pump, use of appropriate compression garments, regular exercise, elevation, and 
manual lymph drainage. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the 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. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and treatment (93284, 99205, 93000) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve consultation and treatment. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the records received do not indicate that the enrollee has an emergent 
or urgent medical condition or is in need of specialized services that are not available in the network. The 
enrollee has an HMO plan. There are in-network providers within a reasonable distance from the enrollee's 
location that can provide 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 
consultation and treatment (93284, 99205, 93000) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve enrollment in the Special Supplemental Benefits for the 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you would like to appeal this denial. The Plan 
denied your request. The Plan says that there is no documentation that the enrollee meets the coverage criteria. 
 
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. Specifically, the provided Attestation Form indicates that the enrollee meets the 
criteria for the SSBCI benefit enrollment. Therefore, we decided that the Plan has to pre-approve enrollment in 
the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.  
 
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: 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 services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 that the enrollee does not require intensive rehabilitation therapy. While the medical 
record supports a need for physical and/or occupational therapy, the enrollee's needs can be met 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) (93702). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 this service. Our reviewer says that the 
requested service is considered medically reasonable and necessary in this case. Our physician reviewer found 
that breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast 
cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data 
has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are 
less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy 
(BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of 
chronic BCRL with level I evidence. This service is reasonable and 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 this service have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702).  
 
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 Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has been on this medication multiple 
times. You also say that you were told this would be covered and now it is not. The Plan denied your request. 
The Plan says tier exceptions reviews are not available for Part B drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that each Part D plan sponsor that provides 
prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must 
establish and maintain reasonable and complete exceptions procedures subject to CMS approval for this type 
of coverage determination.  
 
We looked at the file and Medicare rules. Specifically, Tier exceptions do not apply to Part B drugs. Based on 
this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466) 
 
You asked the Plan to pre-approve a ventilator. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in average volume-assured pressure support (AVAPS) mode with auto-expiratory positive airway 
pressure (AE) that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has severe COPD, severe obesity, and obstructive sleep apnea on BiPAP during 
sleep. An arterial blood gas (ABG) on November 10, 2022, was consistent with chronic carbon dioxide (CO2) 
retention, with a normal potential of hydrogen (pH) and partial pressure of carbon dioxide (PaCO2) of 63. The 
circumstances of the enrollee at the time the ABG was obtained are not provided. This enrollee may benefit 
from BiPAP with AVAPS and a backup rate during sleep. There is no documentation that this has been tried. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. A home 
ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a balloon sinuplasty. 
 
You asked the Plan to pre-approve the requested services. You say that many studies indicate the 
appropriateness and effectiveness. The Plan denied your request. The Plan says the role of the requested service 
remains uncertain. 
 
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 services. Our physician 
reviewer found that the enrollee has chronic sinusitis and congestion. The records provided are insufficient to 
establish the medical necessity of the requested procedure. There is insufficient literature to support the safety 
and efficacy, as defined by Medicare rules, of the requested procedure for the enrollee's condition. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a balloon sinuplasty.
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 services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 that there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. 
 
 
  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.