Persius/hicric huggingface dataset:
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 medication is 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the medication is not medically 
reasonable and necessary or safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says because the drug is being dispensed by a pharmacy it is a Part D covered 
event, and the enrollee does not have Part D coverage through this Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omnipod disposable insulin pump supplies. 
 
You asked the Plan to pre-approve the Omnipod insulin pump supplies. You say that this is medically 
necessary. The Plan denied your request. The Plan says this type of insulin delivery system is not covered by 
Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems such as the 
Omnipod are not covered by Medicare Part B because they are not considered durable medical equipment. 
Therefore, we decided that the Plan does not have to pre-approve the Omnipod disposable insulin pump 
supplies.  
 
Benefits for the Omnipod insulin pump supplies 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says criteria for this level of ventilator are not met. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable and necessary. Our physician reviewer found the enrollee 
has obstructive sleep apnea, obesity-hypoventilation syndrome, and a stated history of chronic obstructive 
pulmonary disease, without pulmonary function tests submitted in the record. Venous blood gases suggest mild 
carbon dioxide (CO2) retention, but chronic CO2 retention was not confirmed by arterial blood gas testing 
done as outpatient while stable. There has been no documented failure of an outpatient trial of bilevel positive airway pressure with average volume-assured pressure support (BiPAP with AVAPS). Based on this 
information, the need for the ventilator is not documented. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
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 IRF care is necessary for the patient to regain 
maximum function. The Plan denied your request. The Plan says IRF care is not medically necessary and the 
patient can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient is medically stable and does not need physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. No rehab nursing needs have been identified or documented in the record. The patient does not 
need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. IRF admission is not medically necessary based on 
medical stability and lack of medical complexity, and lack of rehab nursing needs. While the enrollee may 
benefit from therapy, the patient's rehab can be safely provided at a lower intensity and alternate 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 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: 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 you were independent before your hospitalization 
and you want to return to being independent. You are eager to participate in the aggressive therapy available at 
the IRF and you say you will not get that level of care in a skilled nursing facility. The Plan denied your 
request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care.  Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you are medically stable and do not need physician close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. No rehab nursing needs have been identified or documented in the record. At the 
current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach to daily therapy in an IRF. IRF admission is not 
medically necessary based on medical stability and lack of medical complexity, and lack of rehab nursing 
needs and high functional level. While you may benefit from therapy, your can be safely provided at a lower 
intensity and alternate 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 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 Freestyle Libre 2 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the records provided support the 
need for the requested item. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. The records show that the enrollee is insulin-treated twice a day. Based on 
this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tempur-Pedic foam bed and frame. 
 
You asked the Plan to pre-approve the Tempur-Pedic foam bed and frame. You say that you are sleeping on 
bad bedding that makes your sleep unbearable. You say that the bed you have makes pressure points hurt and 
the requested bed would give you a better nights sleep. You say that the requested bed would enhance your 
health. The Plan denied your request. The Plan says the requested items are not covered benefits. 
 
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 Tempur-Pedic foam bed and frame.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 81479 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on October 
19, 2021. 
 
You asked the Plan to pay for the services. You say that you were told by the doctor that the services would be 
covered. The Plan denied your request. The Plan says the immunization is not covered when the service is 
billed with a non-covered diagnosis. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on April 30, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is not supported in the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15002 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report describes 
debridement for preparing the area for skin graft. To cite the report "The surgical area was then prepped and 
draped in the usual sterile fashion.  Using small bone curettes the sacral wound was carefully debrided in preparation for the graft." In this case, excision cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for plastic surgery services provided to the enrollee on April 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of out-of-network (OON) physical therapy 
(PT) visits. 
 
You asked the Plan to pre-approve continuation of OON PT visits. You say that the requested continuation of 
OON PT visits is medically necessary. The Plan denied your request. The Plan says the requested continuation 
of OON PT visits does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 continuation of OON PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as 
specific and effective therapy for the enrollees condition beyond what was approved by the plan. The enrollee 
has had prior therapy of 30 visits out of network and the documentation does not reveal that the enrollee 
requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The documentation does not reveal extenuating factors that require additional therapy out of network. 
The enrollee has been instructed in a home exercise program.  The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of OON PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of out-of-network (OON) physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed. 
 
You asked the Plan to pay for a total electric hospital bed. You say that a total electric hospital bed was 
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
While a total electric hospital bed may have been appropriate for your use, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided to the enrollee. 
 
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to original Medicare first for review. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transport provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine months of Gammagard Liquid 10% vial. 
 
You asked the Plan to pre-approve nine months of Gammagard Liquid 10% vial. You say that the medication is 
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 nine months of Gammagard Liquid 
10% vial. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the 
member has been authorized for a 3-month trial of the drug. With that said, after the trial of the drug it could 
then ultimately be determined if the drug is safe and effective for this patient. There is not otherwise a basis to 
otherwise permit conclusions without completion of a trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nine months of Gammagard Liquid 10% vial have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nine months of Gammagard Liquid 10% vial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a face down positioning chair or vitrectomy chair provided 
from July 22, 2021 to July 29, 2021. 
 
You asked the Plan to pay for this equipment. You say that the use of this chair was medically necessary after 
eye surgery. The Plan denied your request. The Plan says you did not have prior authorization and this chair is 
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. While this chair may have been appropriate for your comfort during the healing process after 
eye surgery, it is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a face 
down positioning chair or vitrectomy chair provided from July 22, 2021 to July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the Dexcom G6 sensor. You say that you have severe hypoglycemia and 
need alerts for lower sugars. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing 
at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment 
of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating 
physician to assesses adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord. 
 
You asked the Plan to pre-approve endoscopic decompression of spinal cord. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 endoscopic decompression of spinal 
cord. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found endoscopic decompression of the spinal cord remains 
experimental. More research is needed to establish the safety and efficacy of the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endoscopic decompression of spinal cord have not been met. Therefore, we 
decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord.