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

 
We decided that the Plan does not have to pre-approve Antiemetic drug, oral, not otherwise specified, 
Prochlorperazine 10 mg tablets (J8597). 
 
You asked the Plan to pre-approve Prochlorperazine. You say that the enrollee has previously been on 
Prochlorperazine. This is continuation of their medication. The enrollee is on chemotherapy and will need 
Prochlorperazine for breakthrough nausea. The Plan denied your request. The Plan says Prochlorperazine tablet 
does not meets Medicare criteria for coverage under Part B. The Plan does not cover outpatient prescription 
drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Antiemetic drug, oral, not otherwise specified, Prochlorperazine 10 mg 
tablets (J8597).  
 
 
 Benefits for Prochlorperazine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) tomographic (SPECT), single day 
imaging (78803). 
 
You asked the Plan to pre-approve a Brain Spect. You say that the reason no prior imaging has been performed 
is because the enrollee's clinical symptoms are not consistent with any structural brain damage or injury in 
other words stroke, tumor vascular malformation etc. There is no need to get a CT scan or MRI of brain. The 
scan is necessary. The Plan denied your request. The Plan says the coverage criteria has not been supported 
within the submitted documents. 
 
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 Brain Spect. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found DaTSCAN may be used to help differentiate between essential tremor and Parkinsonian 
syndrome, however the sensitivity is low. It cannot be determined that a DaTSCAN is medically reasonable 
and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brain Spect have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) tomographic (SPECT), single day imaging (78803).
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 you are requesting reconsideration of approval for 
inpatient rehabilitation services due to having a right artificial shoulder.  The Plan denied your request. The 
Plan says based on Medicare guidelines, the inpatient rehabilitation facility services you are requesting do not 
meet the requirements for approval. 
 
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 had an elective reverse total shoulder arthroplasty for a chronic rotator cuff 
arthropathy. The records indicate that you can walk twenty feet with a walker and moderate assistance. You 
require maximum assistance for transfers and bed mobility. Your labs and vital signs are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. 
 
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 pre-approve percutaneous image-guided lumbar decompression for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says high quality randomized controlled trials with sufficiently large sample sizes and longer 
follow-up periods are needed to determine if the requested percutaneous and endoscopic spinal surgery 
procedures are more effective than conventional (open approach) procedures. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that high quality randomized controlled trials with sufficiently large sample sizes and longer follow-up 
periods are needed to determine if the requested percutaneous and endoscopic spinal surgery procedures are 
more effective than conventional (open approach) procedures. This is still considered an 
experimental/investigational procedure. Therefore, the request is considered 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says further research is needed to determine whether this device offers a clinically significant 
benefit in comparison with conventional treatments. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke, or other neurological insult or injury, than any 
available standard therapy such as conventional treatments for neurological causes of hemiparesis therapy 
including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if 
needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or 
injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in 
the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve 
hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on April 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that these services were directed by the enrollees in-
network provider. The Plan denied your request. The Plan says that the services were provided out-of-network 
and were not approved in advance. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the genetic testing by a contract provider. The file does not show that the plan 
provided notice that the genetic testing would not be covered. The Plan has indicated this testing was ordered 
by and submitted to the lab by your in-network provider. The Plan contract states the provider, not the enrollee, 
may need to get prior authorization. The enrollee has no option but to trust the plan provider will act on their 
behalf. Under Medicare rules, this means the genetic testing is considered approved by the plan. Therefore, we 
decided that the Plan has to pay for the genetic testing provided on April 2, 2022, by an out-of-network (OON) 
provider.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services (81551) rendered on April 28, 2022. 
 
You asked the Plan to pay for genetic testing services. You say that you want the Plan to pay for the services. 
The Plan denied your request. The Plan says the claim was billed with an inconsistent date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that in most circumstances, the date of service for 
clinical laboratory tests must be the date that the specimen was collected.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing services have not been met. Specifically, the services are not supported because the 
date of service for the case is April 28, 2022, the date of service when testing occurred, instead of the correct 
date of service, January 5, 2022. The specimen was collected on January 5, 2022, which makes it the correct 
date of service. Therefore, we decided that the Plan does not have to pay for genetic testing services (81551) 
rendered on April 28, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You can receive further services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network (OON) 
provider. 
 You asked the Plan to pre-approve the continuation of care services. You say that this care with an OON 
provider continues to be medically necessary. The Plan denied your request. The Plan says they have multiple 
in-network options available for you to choose from. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care services. Our 
reviewer says that the requested continuation of care with an OON provider is not medically reasonable and 
necessary. Our physician reviewer found the record indicates that you have been diagnosed with cataracts. The 
record provided is insufficient to establish that you are currently receiving active treatment such that 
transferring your care and medical management to another provider would be medically inappropriate and/or 
contraindicated at this time. The requested continuation of care with an OON provider is not supported. 
 
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 continuation of care services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the continuation of care with an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation (85060) billed for March 30, 
2022. 
 
You asked the Plan to pay for procedure code 85060. You say that this procedure was reported correctly and 
rendered in an appropriate place of service. The Plan denied your request. The Plan says this code is not 
payable with the place of service (POS) code 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. The rules say no payment is recognized for CPT 
code 85060 furnished to hospital outpatients or non-hospital patients. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this service was billed with a 
POS code of 22 (on campus  outpatient hospital). The rules say that no payment is recognized for this service 
when it is furnished to hospital outpatients. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not have to pay 
for the blood smear interpretation (85060) billed for March 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(code A0998) provided on March 7, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your sugar reading 
was over 600 and you called 911 for assistance. You say that two women came to your home and they 
continued to check your sugar levels and stayed with you until your sugar levels started dropping and they 
made the decision to get you stabilized at home so you would not have to be taken to the hospital. The Plan 
denied your request. The Plan says non transport services are not a covered service by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(code A0998) provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on May 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab, bevacizumab-awwb, and pemetrexed. 
 
You asked the Plan to pre-approve pembrolizumab, bevacizumab-awwb, and pemetrexed. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pembrolizumab, bevacizumab-awwb, 
and pemetrexed. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
the combination of pembrolizumab, bevacizumab-awwb, and pemetrexed is not FDA approved for 
maintenance therapy for metastatic non-small cell lung cancer. Use is not supported by major drug compendia, 
the NCCN Guidelines, or the medical literature. The service is 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 pembrolizumab, bevacizumab-awwb, and pemetrexed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pembrolizumab, bevacizumab-awwb, and 
pemetrexed.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your medical needs can be met at 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 not considered medically reasonable and necessary based on Medicare guidelines. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation.  Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not 
meet Medicare criteria for 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on April 7, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the charges. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit (99214) provided on April 7, 2022 
by an out-of-network (OON) provider.