Persius/hicric huggingface dataset:
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 enrollee is not ready to be discharged home. The 
Plan denied your request. The Plan says the enrollee does not require a complex multidisciplinary approach to 
daily therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital due to confusion. She was diagnosed and treated for a 
urinary tract infection with metabolic encephalopathy, neutropenia and hypokalemia. She stabilized medically. The most recent therapy notes indicate that the enrollee requires assistance with mobility and self-care tasks. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, under the supervision of a physician to regain or maintain her functional status. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 21, 2021 billed 
with codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 21, 2021 billed with codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The 
Plan denied your request. The Plan says the requested Opdivo 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 Opdivo. Our reviewer says that the 
requested Opdivo is not medically necessary. Our physician reviewer found the enrollee has already progressed 
on Opdivo. Taxane with Cyramza and Opdivo is not evidenced based, compendia or literature supported. The 
enrollee should receive Taxane and Cyramza without Opdivo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Heparin sodium and Opdivo. 
 
You asked the Plan to pre-approve Heparin sodium and Opdivo. 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 Heparin sodium and Opdivo. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found 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 Heparin sodium and Opdivo have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Heparin sodium and Opdivo.
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 at a high fall risk and need the IRF to regain 
maximum function. 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 the clinical documentation shows that you are having multiple falls however, there is 
no specific diagnosis given for the underlying reason in regard to the multiple falls.  Intensive therapy would not be a definitive treatment for a clinically significant gain required in IRF criteria. 
The criteria for inpatient rehabilitation admission have not been met and 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the request for a home mechanical 
ventilator set in VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. The Plan 
denied your request. The Plan says the requested ventilator is to be used for the treatment of COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
COPD. An ABG during a recent hospitalization for influenza and pneumonia was consistent with acute on 
chronic hypercarbic respiratory failure. If the enrollee does have chronic CO2 retention, which seems likely, he 
may benefit from BiPAP with AVAPS during sleep as an outpatient. But Medicare does not cover a home 
ventilator when used as BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the documentation does not support why a medial branch block (MBB) was 
not or could not be performed prior to the facet joint injection. The Plan also says the documentation does not 
show why you are not a candidate for radiofrequency ablation (RFA) at the level requested. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria.  
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 injections. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found the provided documentation 
indicates that for each covered spinal region no more than four therapeutic facet joint (IA) sessions will be 
reimbursed per rolling 12 months. The reviewer found that the enrollee had a facet injection on May 12, 2022, 
that resulted in zero pain relief. There is no documentation in the record as to why a medial branch block 
(MBB) was not performed or could not be performed prior to the Therapeutic facet injection. In addition, the 
enrollee also had MBBs at L4-S1 in January 2021 and May 2021 with 100% pain relief. There is no 
documentation as to why the enrollee is not a candidate for radiofrequency ablation (RFA) at that level per the 
guidelines. Therefore, the reviewer found that additional facet joint injections are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant (D6010) and 
prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve these services. You say that you have difficulty eating due to loss of teeth 
and need dental implants. The Plan denied your request. The Plan says that this is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant (D6010) and prefabricated abutment (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that you urgently need this service. The 
Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete denture - maxillary (D5110).
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. The Plan denied your request. The Plan says the enrollee does not 
have complex medical care that requires physician oversight three times per week. 
 
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 physician reviewer found 
that you were admitted to the acute hospital due to weakness in your leg and ambulatory dysfunction. The most 
recent therapy notes indicate that you require moderate assistance to ambulate a few steps and require 
assistance for bed mobility and transfers.  You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0841) and accessories (E2361x2, 
E2377, E2313, E1028x2, e1007, E2620, E0955, E1012, E2311, E2622, K0861). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested wheelchair is not 
medically necessary. A less advanced group 2 power wheelchair with a skin protection cushion may be asked 
to be reviewed. There is no medical need for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation that the power wheelchair with multiple power options at issue in this case meets Medicare 
criteria for medically reasonable and necessary. Provided records do not document a qualifying diagnosis for a 
group 3 power wheelchair. Provided records do not document a neurological condition, myopathy or congenital 
skeletal deformity to meet criteria for a group 3 power wheelchair. Provided records do not support that she is 
high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not 
document the enrollee performs bladder self-catheterization, is unable to transfer independently or has 
increased muscle tone or spasticity, thus she does not meet criteria for the power tilt/recline or the multiple 
power options. 
 
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 and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair (K0841) and accessories (E2361x2, E2377, 
E2313, E1028x2, e1007, E2620, E0955, E1012, E2311, E2622, K0861).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF system. 
 
You asked the Plan to pre-approve a CardioMEMs HF system. You say that the requested CardioMEMs HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMs HF 
system 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 CardioMEMs HF system. Our 
reviewer says that the requested CardioMEMs HF system is not medically necessary. Our physician reviewer 
found the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed in the 
pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, 
reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent 
follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of 
the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies 
examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a 
result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in 
this 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 a CardioMEMs HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMs HF system.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the requested Erbitux is medically necessary. The 
Plan denied your request. The Plan says that the requested Erbitux 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 Erbitux. Our reviewer says that the 
requested Erbitux is medically necessary. Our physician reviewer found the requested use of Erbitux is FDA-
approved for the enrollee's diagnosis of kras/nras wildtype rectal cancer. The use of Erbitux is listed as 
supported per Lexicomp compendia. The documentation supports that the requested Erbitux is safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have been met. Therefore, we decided that the Plan has to pre-approve 
Erbitux.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided December 14, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you need quality hearing aids and feel these should 
be covered. The Plan denied your request. The Plan says the hearing aids are not covered because they were 
provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were provided out-of-network without 
contacting the Plans hearing aid vendor. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aid, digital, binaural, behind the ear (V5261) provided December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide 48 additional routine transportation trips for 2022. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to your ongoing dialysis appointments. The Plan denied your request. The Plan says your benefit covers up to 
60 routine transportation trips each year. Additional trips are 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 60 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 provide 48 additional routine transportation trips for 2022.