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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support that Keytruda is 
medically necessary for the enrollee's treatment. The Plan denied your request. The Plan says this is an off-
label use that is not medically accepted. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the requested use of Keytruda is not 
FDA-approved for the enrollee's diagnosis. The use of Keytruda is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services 
for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the required skilled rehab and nursing services can be met safely and 
effectively at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Clinical documentation 
shows that patient has multiple active comorbidities that would require close medical supervision on an 
inpatient basis. Both evaluating physical and occupational therapy recommend intense therapy and that patient 
would tolerate intense therapy. A non-traumatic brain injury (encephalopathy) is an IRF compliant diagnosis. 
Our physician reviewer found that the enrollee's condition meets criteria for coverage of IRF 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the longer the enrollee waits, the more her health 
will decline. You say that without IRF care the enrollee will get weaker and lose more muscle strength. The 
Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee could receive the care needed in another 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 
was admitted for a urinary tract infection. The enrollee's 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits (97164). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that the clinical documentation shows that you 
have made functional gains with physical therapy to now use a single point cane from a walker or two canes. 
The evaluating therapist states that you have made a rehabilitation plateau and does not make any specific 
recommendations for additional therapy. There is no supporting documentation regarding complexity or change 
in diagnosis from the provider; thus, ten additional physical therapy sessions are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten additional physical therapy visits (97164).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided March 31, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this claim met all of the Medicare's DME LCD 
coverage criteria. 
 The Plan denied your request. The Plan says the documentation provided do not support payment for this 
service. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal detailed upper extremity physical exam findings or 
indications in the medical progress notes for the need of the requested L3916. The requested item exceeds the enrollees medical need. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the wrist hand orthosis (L3916) provided March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services, x-ray and clinic visit provided on March 
17, 2022 and March 30, 2022 by an OON provider. 
 
You asked the Plan to pay for laboratory services, x-ray and clinic visit. You say that you were not notified that 
the provider for the year 2022 would be considered out-of-network. The Plan denied your request. The Plan 
says you must use in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services, x-ray and clinic visit provided 
on March 17, 2022 and March 30, 2022 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should cover second 
opinions when trying to establish with a new dentist. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteopenia of multiple sites. The documentation does not support that the enrollee has 
tried and failed zoledronic acid. The documentation does not support that zoledronic acid would likely be less 
effective and/or likely have adverse effects for the enrollee. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you paid your specialist office visit 
and didn't know there was another charge for the test. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for Medicare-covered outpatient diagnostic tests.  
 
You have been asked to pay $50 copayment for endoscopy. Endoscopys fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for endoscopy provided on March 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the premium lens and post-op bag you received on October 
20, 2021. 
 You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says these services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are not covered by Medicare or the Plan. Therefore, we decided that 
the Plan does not have to pay for the premium lens and post-op bag you received on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ostomy pouches coded A5063 provided on August 30, 
2021, to November 29, 2021. 
 
You asked the Plan to pay for the ostomy pouches. You say that you disagree with the plan's denial. The Plan 
denied your request. The Plan says the items billed are not separately payable. 
 
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 A5063 is ostomy pouch, drainable; for use on barrier 
with flange (2 piece system), each. 
 
We find that CPT code A5063 is not supported in the medical record. Specifically, this code has a status code 
of "P". A status code P means that this code is a bundled/excluded code. There are no relative value units 
(RVUs) and no payment amounts for these services. No separate payment should be made for them under the 
fee schedule. Based on this information, we decided that Medicare rules for coverage of the ostomy pouches 
have not been met. Therefore, we decided that the Plan does not have to pay for the ostomy pouches coded 
A5063 provided on August 30, 2021, to November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, immune globulin, (gammaplex), intravenous, non-
lyophilized (e.g., liquid), 500 mg (J1557) provided November 30, 2021 to December 21, 2021. 
 
You asked the Plan to pay for . You say that per Medicare guidelines attached D80.4 is a covered LCD 
diagnosis code. Please review the attached support and process the claim for payment. The Plan denied your 
request. The Plan says procedure code J1557 has not met the associated diagnosis code relationship criteria. 
 
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 pay for the infusion services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there was no documented evidence of rapid progression of a covered disease or 
relapse, or when other forms of treatment have failed or are contraindicated. There was no physician 
documentation of the rationale for the choice of therapy considering the disease activity, concurrent illness, 
venous access, side effects and drug availability in the decision of which therapy to prescribe and in what 
sequence. No required testing, evaluation or plan could be found in the documentation. IVIG therapy is only 
considered medically reasonable and necessary for neurological disorders when there is evidence of rapid 
progression of the disease or relapse or when other forms of treatment have failed or are contraindicated. The 
physician must document the rationale for the choice of therapy and consider disease activity, concurrent 
illness, venous access, side effects and drug availability in the decision of which therapy to prescribe and in what sequence. Medicare requires periodic reevaluation of immune-globulin (IgG) level(s) to determine dose 
and frequency of treatments for covered diagnoses. The review has determined that the records did not support 
that this service meets the medically necessary criteria for Medicare coverage. 
 
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 infusion services have not been met. Therefore, we decided that the Plan 
does not have to pay for injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 
500 mg (J1557) provided November 30, 2021 to December 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drugs, Orthovisc or Supartz FX. 
 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 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternatives. Therefore, the reviewer found that the step therapy criteria have not been 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
27, 2021, to May 7, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were reimbursed the 
wrong amount. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment each day for days 1 through 7 for Medicare covered hospital care. $0 copayment for additional 
Medicare-covered days.  
 
You have been asked to pay $1,750 copayment for inpatient hospital care. Inpatient hospital care falls within 
the Inpatient Hospital 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 from April 27, 2021, to May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Retacrit or Procrit. 
 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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the plan's preferred drugs, Retacrit or Procrit. The reviewer found 
that the documentation does not support that Retacrit or Procrit would likely be less effective, and/or would 
likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy 
criteria have not been 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided from May 
12, 2021, to May 24, 2021. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you reached your out-of-
pocket maximum before these services were billed. The Plan denied your request. Your out-of-pocket 
maximum for 2021 is $2,900. At the time the claims were received you had not met your out-of-pocket 
maximum. The Plan says the copayments applied are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for each Medicare-covered physical therapy and speech-language therapy visit.  
 
 
 You have been asked to pay $105 ($35 x 3 visits) copayment for physical therapy visits. Physical therapy visits 
fall within the Outpatient Rehabilitation Services 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 physical therapy visits provided from May 12, 2021, to May 24, 2021.