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

 
We decided that the Plan does not have to pre-approve Dofetilide. 
 
You asked the Plan to pre-approve Dofetilide. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not covered under Medicare Part B. The Plan says that 
they do not administer the enrollee's pharmacy benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dofetilide.  
 
Benefits for Dofetilide may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on July 18, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that there is inadequate documentation provided to 
support the medical necessity for repeat professional visits at a frequency exceeding Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a valid Medicare rule to substantiate the 
denial. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided on  
July 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that you are request a prior authorization with 
Gap exceptions, for a MyoPro Motion G for the treatment of the enrollee's left upper extremity partial paralysis 
since suffering a stroke. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. There is insufficient evidence of its safety and effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing this denial. The Plan 
denied your request. The Plan says there is no documentation that the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the SSBCI benefits have been met. The 
medical records were not received from the provider. Therefore, we decided that the Plan does not have to pre-
approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefits.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection, Cemiplimab-rwlc, 1 mg (code J9119) provided on 
July 6, 2022 
 
You asked the Plan to pay for an injection, Cemiplimab-rwlc, 1 mg (code J9119). You say that the injection, 
Cemiplimab-rwlc, 1 mg is medically necessary. The Plan denied your request. The Plan says that the requested 
drug is experimental/investigational. 
 
The Plan follows Medicare rules.  
 
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 an injection, Cemiplimab-rwlc, 1 mg (code 
J9119). Our reviewer says that an injection, Cemiplimab-rwlc, 1 mg is medically necessary. Our physician 
reviewer found that Cemiplimab is FDA approved for the treatment of metastatic cutaneous squamous cell 
carcinoma (cSCC) or locally advanced cSCC in patients who are not candidates for curative surgery or curative 
radiation. Treatment is until toxicity or progression. This enrollee meets these criteria. The service is 
reasonable and medically necessary for this patient.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an injection, Cemiplimab-rwlc, 1 mg (code J9119) have been met. Therefore, 
we decided that the Plan has to pay for the injection, Cemiplimab-rwlc, 1 mg (code J9119) provided on 
July 6, 2022  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutch substitute (E0118) and positioning wedge pillow 
(E0190). 
 
You asked the Plan to pay for the crutch substitute and pillow. You say that the durable medical equipment was 
prescribed by the doctor for a broken ankle. You are non-weight bearing and needs to keep it elevated. The 
Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety 
and effectiveness in the Medicare population to establish the medical necessity for the crutch substitute. 
Disposable items such as wedge pillow are not covered by Medicare. 
 
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 pay for the crutch substitute (E0118) and positioning wedge pillow 
(E0190).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Barostim Neo system (C1825 and 0266T). 
 
You asked the Plan to pre-approve the system. You say that the Barostim Neo system is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the Barostim Neo system in 
the setting of congestive heart failure have not been demonstrated in the peer-reviewed literature. The Plan 
states there remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of BaroStim Neo in patient management. 
 
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 system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains an absence of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim 
Neo system would not be considered medically reasonable and necessary in this enrollees 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Barostim Neo system (C1825 and 0266T).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera. 
 
You asked the Plan to pre-approve Trazimera. You say that the requested drug is medically necessary for 
treatment of the enrollee's metastatic bladder cancer. The Plan denied your request. The Plan says the requested 
drug is not being prescribed for a supported medically accepted indication. 
 
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 Trazimera. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Trazimera is not 
FDA-approved for the enrollee's diagnosis. The use of this drug is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. Studies to date for 
human epidermal growth factor receptor 2 (HER2) positive bladder cancer have been disappointing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Trazimera have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trazimera.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kadcyla and Perjeta. 
 
You asked the Plan to pre-approve Kadcyla and Perjeta. You say that the medical records provided support the 
need for the drugs in dispute. The Plan denied your request. The Plan says the mix of the requested drugs is not 
supported for the enrollee's type of cancer. 
 
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 Kadcyla and Perjeta. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the requested use of Kadcyla 
and Perjeta is not FDA-approved for the enrollee's diagnosis. The use of these drugs is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical 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 Kadcyla and Perjeta have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Kadcyla and Perjeta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the medical records provided 
support the need for the requested device. The Plan denied your request. The Plan says the records do not show 
that the enrollee has had a negative or inconclusive test result for test of cardiac rhythm. The Plan says that he 
requested device 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 an implantable loop recorder. Our 
reviewer says that an implantable loop recorder is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is a history of near-syncope (the patient denies syncope), with no 
history of an ambulatory electrocardiogram (ECG) monitor having been performed to assess a possible 
arrhythmic etiology of her dizzy spells. There is insufficient documentation to support the medical necessity for 
insertion of an implantable loop recorder 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Foresee-home visual field assessment monitoring 
(0379T). 
 
You asked the Plan to pre-approve the Foresee home device. You say that please see the attached information 
to show medical necessity signed off by the referring physician. The Plan denied your request. The Plan says 
this type of monitoring has not been proven to be as good or better than standard monitoring to detect changes 
in vision with macular degeneration and has not been proven to improve long-term results for patients with this 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Foresee home device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Foresee-home visual field assessment monitoring (0379T).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for subsequent nursing facility care provided on July 19, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that there is inadequate documentation provided to 
support the medical necessity for repeat professional visits at a frequency exceeding Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a valid Medicare rule to substantiate the 
denial. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided on 
July 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral knee orthoses (L1851 X 2) and suspension sleeves 
(L2397) provided 
 
You asked the Plan to pay for the orthoses and sleeves. You say that the orthoses and sleeves are medically 
necessary. The Plan denied your request. The Plan says knee instability must be documented by examination of 
the beneficiary and objective description of joint laxity.  
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 orthoses and sleeves. Our physician 
reviewer found the documentation does not reveal objective physical exam evidence of knee instability. There 
is no evidence of recent injury or surgery to the knees. The documentation does not reveal a clear gait exam or 
indications of the enrollee's ambulatory function. The criteria for the requested knee orthosis L1851 have not 
been met per LCD L33318. 
 
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 orthoses and sleeves have not been met. Therefore, we decided that the Plan 
does not have to pay for bilateral knee orthoses (L1851 X 2) and suspension sleeves (L2397) provided
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on August 4, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport provided on 
August 4, 2022. You say that the medical records provided support the need for the ambulance transport. The 
Plan denied your request. The Plan says the ambulance transport was not medically necessary 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport provided on August 4, 2022. Our reviewer says that the ambulance transport was not 
medically necessary.  Our physician reviewer found the transportation via ambulance upon hospital discharge was not medically 
necessary.  The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 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 the ambulance service, basic life support, non-emergency transport provided on 
August 4, 2022. 
 have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic 
life support, non-emergency transport provided on August 4, 2022.
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 LTACH is medically necessary. The 
Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs can be 
met at a different care setting such as an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF) 
or at home with home health services. 
 
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 has a past medical history of difficulty eating, indigestion, heart failure, 
high blood pressure, irregular heartbeat, confusion, weakness and swelling to legs who was admitted to the 
hospital for worsening tremors. While in the hospital the enrollee was treated for systemic infection, abnormal 
heart rhythm, low heart rate, constipation, elevated cardiac markers and constipation. After the hospitalization, 
the enrollee was transferred to a skilled nursing facility to receive intravenous immunotherapy. However, the 
enrollee was brought back to the hospital due to tremors. The hospital stay was further complicated by systemic infection and respiratory failure. The enrollee is currently intubated and has a feeding tube. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic hernia repair provided out-of-area 
(OOA.) 
 
You asked the Plan to pre-approve the OOA laparoscopic hernia repair. You say that you traveled to Chicago 
because of a family emergency and developed a hernia that is extremely painful and debilitating. You say that 
the hernia will become larger and more painful as time passes and that you cannot wait until returning to the 
service area to have the requested procedure performed. The Plan denied your request. The Plan says the 
requested surgery is not emergent because it is not scheduled to be performed until April. The Plan say that 
there are network providers who can perform the services being requested when the enrollee returns to the 
service area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 OOA laparoscopic hernia repair. 
Our reviewer says that the criteria for OOA coverage have not been met. Our physician reviewer found the 
records show notes from December saying that the enrollee had the hernia and some symptoms while in 
Florida. Therefore, the enrollee could have foreseen requiring the services prior to leaving his service area and 
the requested services do not meet the definition of urgent care. There was no documentation that the 
symptomatic inguinal hernia was at risk of emergent repair generally within a 24-to-72-hour window. The 
enrollee was scheduled for an elective repair. The hernia repair is medically necessary, but not in an emergent 
timeline. 
 
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 OOA laparoscopic hernia repair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a laparoscopic hernia repair provided out-of-area (OOA.)