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

 
We decided that the Plan does not have to pay for the percutaneous lumbar decompression with fluoroscopic 
guidance and epidurogram (0275T), provided on Decemebr 15, 2021. 
 
You asked the Plan to pay for the percutaneous lumbar decompression. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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 pay for the percutaneous lumbar decompression. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting and there is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 percutaneous lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous lumbar decompression with fluoroscopic 
guidance and epidurogram (0275T), provided on Decemebr 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glucose test strips (A4253), purchased on December 6, 
2021. 
 
You asked the Plan to pay for the glucose test strips. You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item.  
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the glucose test strips have not been met. Specifically, there was no medical documentation 
sumbitted to indicate the requested strips are medically necessary over the Plan's preferred strips. Therefore, we 
decided that the Plan does not have to pay for the glucose test strips (A4253), purchased on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint denervation. 
 
You asked the Plan to pre-approve facet joint denervation. You say that the requested facet joint denervation is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint denervation. 
 
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 facet joint denervation. Our reviewer 
says that the enrollee does not meet criteria for the requested facet joint denervation. Our physician reviewer 
found Medicare requires 2 separate sets of diagnostic medial branch blocks (MBBs) that achieve 80% pain 
relief.  Since there has not been a second set of blocks performed, at this point, the request is deemed 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 facet joint denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint denervation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) filters, 
provided on November 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP filters. You say that the items should be covered. The Plan denied your 
request. The Plan says you did not purchase this item through an in-network provider. 
 
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 the continuous positive airway pressure (CPAP) 
filters, provided on November 24, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services beyond June 10, 2022. 
She was treated with intravenous fluids due to COVID positive status with poor appetite on June 10, 2022. 
Provided records do not document further intravenous medications or other need for ongoing skilled nursing 
services beyond this date. Based on the medical records provided this enrollee does require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and 
effectively provide medically necessary and reasonable treatment. Based on the medical records provided there 
is no documentation that further daily skilled services are required. The enrollee is walking household distances 
with a rolling walker with contact guard to minimum assistance and is contact guard assist for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate further 
daily inpatient skilled therapy services. Based on the medical records provided there is no documentation that 
the enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquablation of your prostate (0421T). 
 
You asked the Plan to pre-approve aquablation of your prostate. You say that the requested procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure does not meet 
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 aquablation of your prostate. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the records do not show that the IPSS was greater than 12 and that a 
uroflow was not done. The records also do not show that the enrollee has not failed first line treatment with 
medications. The enrollee has not received medical treatment for BPH and lower urinary tract symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquablation of your prostate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve aquablation of your prostate (0421T).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair lift (E1399). 
 
You asked the Plan to pre-approve a chair lift. You say that the enrollee lives in a two-story home in which all 
bedrooms are located on the 2nd level. Without the chair lift, the enrollee is confined to one part of the home. 
The Plan denied your request. The Plan says the chair lift that you are requesting would be helpful even to 
those who do not have a specific medical problem. Therefore, Medicare does not consider it to be primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a chair lift (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) (01396), provided on 
October 28, 2021. 
 
You asked the Plan to pay for the monitored anesthesia care. You say that the service was medically necessary 
The Plan denied your request. The Plan says the service was not medically necessary 
 
The Plan follows Medicare rules. Medicare rules say that monitored anesthesia care (MAC) service rendered 
must be reasonable, appropriate, and 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 pay for the monitored anesthesia care. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found there is no record of a medical 
condition that is significant enough to impact the need to provide monitored anesthesia 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 monitored anesthesia care have not been met. Therefore, we decided that the 
Plan does not have to pay for the monitored anesthesia care (MAC) (01396), provided on October 28, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve continued treatment and care with the out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve continued treatment and care with the OON provider. You say that the 
continued treatment and care with the OON provider is medically necessary as the in-network provider cannot 
see the enrollee for two months and this could result in interruption of the enrollee's care. The Plan denied your 
request. The Plan says that there are in-network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We looked at the file and Medicare rules. The file shows that the enrollee is currently receiving active 
treatment and medical management of her condition that makes it medically necessary for this enrollee to 
continue care with the OON provider as requested. The Plan has not shown that they have in-network 
specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of the enrollee's condition without interruption. At this time, the enrollees medical 
management and follow-up care cannot be safely transitioned to an in-network provider as there is no in-
network providers available to the enrollee for two months. The enrollee cannot be expected to pause oncology 
treatment until a plan provider becomes available. Based on this information, we decided that Medicare rules for coverage of continued treatment and care with the OON provider have been met. Therefore, we decided that 
the Plan has to pre-approve continued treatment and care with the 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: 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is somewhat unstable and requires 
additional short-term acute care services that can be safely administered at the current facility until more stable 
and appropriate for 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires high levels of supplemental oxygen and requires ongoing acute 
care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, 
and these have not been denied. The medical record does not indicate that the enrollee requires services that she 
is not currently receiving but that would be available at the LTACH facility. 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the requested MyoPro powered 
arm brace is medically necessary. The Plan denied your request. The Plan says the requested MyoPro powered 
arm brace 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 MyoPro powered arm brace. Our 
reviewer says that the requested MyoPro powered arm brace is not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the requested MyoPro 
powered arm brace meets Medicare criteria for medically reasonable and necessary for the enrollee in this case. 
Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched 
conventional upper limb exercise therapies" with unproven benefit in the home environment. Although records 
from the device manufacturer/vendor argue medical necessity of the requested device, no records from the 
enrollees actual treating provider clarify why the requested device is the most appropriate treatment for the 
enrollees condition.  
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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3, with multiple power 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair, group 3, with multiple power accessories. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met. 
 
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 power wheelchair, group 3, with 
multiple power accessories. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found the documentation does not indicate that the member has any pressure injuries or requires 
intermittent catheterization of the bladder that would necessitate power tilt or recline. The requested leg rests 
are not medically necessary as the member does have significant edema or a musculoskeletal condition or the 
presence of a cast or brace which prevents 90-degree flexion at the knee. 
 
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 power wheelchair, group 3, with multiple power accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 3, with 
multiple power accessories.
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 requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda 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 
requested Keytruda is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of pancreatic cancer. The record does not indicate that the enrollee's tumor exhibits 
microsatellite instability-high (MSI-H), mismatch repair deficient (dMMR) or tumor mutational burden-high 
(TMB-H) of greater than or equal to 10 mut/Mb. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.