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. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements. 
 
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 physician reviewer 
found that the enrollee has metastatic head and neck squamous cell carcinoma. The requested use of Keytruda 
is not FDA approved without PD-L1 testing. The requested use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not 
indicated, not supported or not recommended in any of the compendia. The documentation does not support 
that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on September 22, 2021. 
 
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 the date of service for a clinical laboratory test or the technical component of physician 
pathology service must be the date the specimen was collected. 
 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. 
 
The date of service in this case should be the date that the specimen was collected, which would be September 
8, 2021. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services rendered on September 
22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen or methane test. 
 
You asked the Plan to pre-approve a breath hydrogen or methane test. You say that the requested testing is 
medically necessary. The Plan denied your request. The Plan says the Medicare coverage rules have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that testing of lactulose breath hydrogen for diagnosing 
small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. 
 
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 breath hydrogen or methane test. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
symptoms of possible small intestinal bacterial overgrowth for which her provider has ordered breath hydrogen testing. No re-evaluation was provided after the enrollee was asked to begin a low fermentable oligo-, di- and 
monosaccharides, and polyols (FOD-MAP) diet, assessment for pelvic floor dysfunction, and testing by breath 
hydrogen for small intestinal bacterial overgrowth. Medicare specifically excludes for coverage lactulose 
breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit 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 a breath hydrogen or methane test have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a breath hydrogen or methane test.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not require skilled nursing and skilled therapy services. The 
medical records do not support that continued services in the acute inpatient rehabilitation facility are not 
appropriate until the enrollee is stable to transfer to 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP 
(AE) that could be delivered by 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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this 
case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee has a distant history of hypercarbia. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 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. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27279). 
 
You asked the Plan to pre-approve sacroiliac joint fusion. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet coverage 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 pre-approve sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding imaging studies corroborating 
pathology of the sacroiliac joint. Additionally, the most recent exam dated October 19, 2022, did not 
demonstrate objective deficits to the sacroiliac joint outside of tenderness to palpation. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
Please note: the Plan used LCD L36406 which is not valid for the state of Florida where the service is to take 
place. Therefore, we did not use these rules when making our decision.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint fusion (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom queen-sized hospital bed (E1399). 
 
You asked the Plan to pre-approve a hospital bed. You say that you are sleeping in his wheelchair because the 
bed you received is a twin sized standard hospital bed. IT is too small as you weigh 260 pounds and is 6 feet 
tall. The Plan denied your request. The Plan says this request is not medically necessary, and the records do not 
show that the approved standard hospital bed will not meet the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical condition which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the submitted medical documentation does not support that the enrollees condition requires 
positioning of the body, to alleviate pain, to promote good body alignment, prevent contractures, avoid 
respiratory infections, in ways not feasible in an ordinary bed. The submitted documentation does not support 
that the enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed. An 
August 11, 2022 telephone follow up visit states that the enrollee denies fatigue, weight loss, headache, 
dizziness, neck pain, shortness of breath, orthopnea or PND, oxygen dependence, sleep apnea, shortness of 
breath, wheezing, joint pain, joint swelling, muscle pain/myopathy or loss of strength. The August 11, 20222 
submitted progress note does not discuss the need for a hospital bed. The criteria for the requested bed have not 
been met per Centers for Medicare and Medicaid Services (CMS), Internet-Only Manual, Publication 100-03, 
Medicare National Coverage Determinations Manual, Chapter 1, Section 280.7.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom queen-sized hospital bed (E1399).
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 the home ventilator. You say that the home ventilator is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found there is no 
documentation that this patient has neuromuscular disease, thoracic restrictive disease, or chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. 
 
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 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 home ventilator. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that you have a 
condition for which a home ventilator is covered. It is documented that you have chronic obstructive 
pulmonary disease (COPD) but no increased carbon dioxide in your blood (hypercarbia) or low level of oxygen 
in your tissue (hypoxia). There are no pulmonary function tests or pulmonary imaging provided. The home 
ventilator is therefore not reasonable or 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 a home ventilator.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy. 
 
You asked the Plan to pre-approve the requested services. You say that you have tried several different 
methods of losing weight. The Plan denied your request. The Plan says that you do not have a qualifying 
comorbid condition. 
 
The Plan follows Medicare rules. Medicare rules say that surgical management of morbid obesity is only 
covered under certain medical indications.  
 
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 you have a BMI 41.66 kg/m2. Weight related co-morbid conditions include 
gastroesophageal reflux disease (GERD), ankle pan and hypercholesterolemia. You have failed numerous 
dietary efforts in the past. The records show that you do meet the criteria for the requested service. Therefore, 
the request is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a laparoscopic sleeve gastrectomy.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS system. 
 
You asked the Plan to pre-approve the CardioMEMS system.. You say that the records provided support the 
need for the CardioMEMS system. The Plan denied your request. The Plan says the requested procedure 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 the CardioMEMS system. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients 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 the CardioMEMS system. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for medical complications 
and requires the continued daily medical oversight provided at an IRF. You also say that the enrollee's goal is 
to return home and resume their fully independent life. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  Specifically, 
the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  The enrollees care 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower limb prosthesis with advanced features (L5981, 
L5988). 
 
You asked the Plan to pay for the lower limb prosthesis with advanced features. You say that this prosthesis is 
medically necessary. The Plan denied your request. The Plan says insufficient records were provided to support 
this item. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a lower limb prosthesis with advanced 
features (L5981, L5988). have been met. No clinical records were provided to support the request. Therefore, 
we decided that the Plan does not have to pay for a lower limb prosthesis with advanced features (L5981, 
L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all-lower extremity prostheses, flex-walk system or 
equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968). 
 
You asked the Plan to pre-approve the K3 advanced foot and ankle. You say that your activity has increased, 
and you need a new foot that will meet your needs. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for the requested prosthetic foot and multiaxial ankle. 
 
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 K3 advanced foot and ankle. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee was being treated for acquired absence of right leg below the 
knee. The enrollee presented with skin ulceration. This is mild and improving. The exam reveals the enrollee 
walked in the office with a cane using their prothesis. However, detailed documentation is not evident 
regarding that the enrollee's current functional status is being at the level required by the requested foot. The 
enrollee is noted to be a K2 level and the prosthesis is a K3. Moreover, the enrollee was noted to be ambulating 
with the assistance of a cane. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested K3 advanced foot and 
ankle (L5981 and L5968), in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the K3 advanced foot and ankle have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the all-lower extremity prostheses, flex-walk system or equal (L5981) 
and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968).