Persius/hicric huggingface dataset:
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 a home ventilator. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. You say that you are appealing so the enrollee can get the 
equipment/devices they need to help make their daily lives for the better. The Plan denied your request. The 
Plan says Medicare does not cover durable medical equipment (DME) in a skilled nursing facility (SNF) (long 
term care facility) or inpatient facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital 
interatrial communication. 
 
You asked the Plan to pre-approve percutaneous transcatheter closure of congenital interatrial communication. 
You say that the service is necessary for the enrollee. The Plan denied your request. The Plan says the 
requested 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 pre-approve percutaneous transcatheter closure of 
congenital interatrial communication. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested PFO closure in this patient's 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 percutaneous transcatheter closure of congenital interatrial communication have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous transcatheter 
closure of congenital interatrial communication.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pair of sunglasses. 
 
You asked the Plan to pre-approve these services. You say that you need the sunglasses after cataract surgery. 
The Plan denied your request. The Plan says the services are not covered. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses after cataract surgery and one routine complete pair of 
eyeglasses per year. 
 
We looked at the file and the Plan's rules. The item at issue is a pair of sunglasses. These services are not 
covered by your supplemental routine vision benefit or your medical benefit. Therefore, we decided that the 
Plan does not have to pre-approve a pair of sunglasses.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgery to be provided by an out-of-network 
(OON) provider. 
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
vascular surgery to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occupational therapy visit provided on May 10,2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an occupational therapy visit. You say that you are appealing the claim payment 
denial for services rendered on May 10, 2022. The Plan denied your request. The Plan says an authorization 
was not obtained prior to services rendered. 
 
  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 occupational therapy visit provided on May 
10,2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and an electrocardiogram to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits and an electrocardiogram to be provided by an OON provider. 
You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says 
the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-
network specialists available to you that can provide care and treatment for postural orthostatic tachycardia 
syndrome (POTS). The Plan also says that tertiary care is available in-network if the primary cardiologist needs 
a consultation or assistance in managing your condition. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits and an electrocardiogram to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the carotid ultrasound testing provided on June 15, 2022. 
 
You asked the Plan to pay for the carotid ultrasound testing. You say that this was a medically necessary test. 
The Plan denied your request. The Plan says the primary diagnosis code is not a covered code per the LCD. 
 
The Plan must follow Medicare rules. Medicare rules say that cerebrovascular arterial studies, such as carotid 
ultrasound, may be covered when one of the conditions listed in the LCD are met.  
 
We looked at the file and Medicare rules. None of the reported diagnosis codes correspond to a covered 
sign/symptom for this testing. The record notes just that this was done prior to a surgery, but there is no 
documentation of a bruit, a history of previous neurological event, or documented clinical suspicion of carotid 
occlusion as required. Based on this information, we decided that Medicare rules for coverage of the carotid 
ultrasound testing have not been met. Therefore, we decided that the Plan does not have to pay for the carotid 
ultrasound testing provided on June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior non-segmental instrumentation (22840) and 
arthrodesis (22612). 
 
You asked the Plan to pre-approve posterior instrumentation and arthrodesis. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested services are 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 posterior instrumentation and 
arthrodesis. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there is no evidence of instability clearly documented 
in the record.  The enrollee has multi-level foraminal stenosis which is not treated with posterior 
instrumentation. The request 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 posterior instrumentation and arthrodesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve posterior non-segmental instrumentation (22840) and 
arthrodesis (22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab/Opdivo. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there is no phase III 
trial data for this drug for the enrollee's diagnosis. This use is not supported or indicated by any of the 
Medicare-approved compendia. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nivolumab/Opdivo.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you do not drive or have much help 
with transportation. The Plan denied your request. The Plan says 30 one-way trips are covered per calendar 
year, the 31st and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 30 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional trips. 
 
You asked the Plan to pre-approve 13 additional trips. The Plan denied your request. The Plan says your 
benefit only allows 60 one-way trips per calendar year. The Plan also says that this request exceeds your 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 13 additional trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye 
under the Vision care benefit category.  
 
 
 
 
 The record shows that you were seen for a medical eye exam for the diagnosis of unspecified blepharitis of the 
right eye and upper and lower eyelid. You have been asked to pay a $10 copayment for the eye exam. This 
item/service falls within the Vision care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the eye exam provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmic biometry (92136) provided 
on April 7, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmic biometry. You say that you never saw the 
doctor or received a medical exam. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. The Plan also says that it was confirmed with the provider's office that your eye screening began but 
you left in the middle of it, prior to seeing the doctor to finish the exam for intraocular lenses. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for services obtained from a specialist.  
 
 
 
 
 You have been asked to pay a $30 copayment for the ophthalmic biometry. This item/service falls within the 
Physician/Practitioner Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ophthalmic biometry (92136) provided on April 7, 2022.  
 
Your complaint about not being seen for the exam is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Keytruda (pembrolizumab) in combination 
with dabrafenib and trametinib. 
 
You asked the Plan to pre-approve the additional use of Keytruda. You say that it is felt that Keytruda should 
be included in the treatment regimen. The Plan denied your request. The Plan says Keytruda is not supported 
for treatment at this time. 
 
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 the additional use of Keytruda. Our 
reviewer says that the inclusion of Keytruda in the planned treatment is not considered medically reasonable 
and necessary. Our physician reviewer found the enrollee has metastatic cancer of occult origin, possibly 
gastrointestinal, but it is being treated as lung cancer. Keytruda is FDA-approved for non-small cell lung 
cancer; however, since the enrollee has a BRAF V600E mutation, first-line treatment should be dabrafenib and 
trametinib alone.  
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 additional use of Keytruda have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the use of Keytruda (pembrolizumab) in combination with dabrafenib 
and trametinib.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro treatments. 
 
You asked the Plan to pre-approve the requested use of Darzalex Faspro. You say that it is felt that the 
requested drug should be approved. The Plan denied your request. The Plan says the enrollee must try the 
preferred step one drugs before this can be approved. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested use of Darzalex Faspro. 
Our reviewer says that the requested medication is not reasonable and necessary based on step therapy criteria. 
Our physician reviewer found the Plan requires a trial of drug a proteasome inhibitor (for example: bortezomib 
or carfilzomib) and an immunomodulatory drug (for example: thalidomide, lenalidomide, or pomalidomide) 
before they will approve the requested drug. In this case, the patient has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely be less 
effective and/or likely have adverse effects for the 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 the requested use of Darzalex Faspro have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Darzalex Faspro treatments.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested PBRT. You say that this is a medically necessary treatment. 
The Plan denied your request. The Plan says that the requested treatment is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve the requested PBRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the theoretical advantage of proton beam therapy is in its dose distribution. Proton beam 
therapy thus permits the delivery of high doses of radiation treatment (RT) to the target volume while limiting 
the "scatter" dose received by surrounding tissues.  Use of proton beam RT is expanding as more proton beam 
treatment centers open. However, there are no randomized trials comparing proton beam therapy with photon 
therapy or brachytherapy in men with clinically localized prostate cancer. A systematic review of the available 
evidence from American Society for Radiation Oncology (ASTRO) on efficacy and toxicity concluded that 
outcomes were similar with proton beam therapy and intensity-modulated radiation therapy (IMRT) using 
photons but did not demonstrate a benefit for the proton beam approach. 
 
Other clinical practice guidelines conclude that proton beam therapy offers no clinical advantage over other 
forms of definitive treatment.  The NCCN Panel believes no clear evidence supports a benefit or decrement to 
proton therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated 
prostate proton therapy can be considered a reasonable alternative to x-raybased regimens at clinics with 
appropriate technology, physics, and clinical expertise. Given the patient was seen at a proton beam center, 
such expertise is available. As such, this treatment is considered reasonable and 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 PBRT have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam radiation therapy (PBRT).  
 
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.