Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the DME provided on April 5, 2022. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you did not know that you had to pay 
for the DME since you returned the equipment. 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 20% 
coinsurance for durable medical equipment.  
 
The record shows this claim was approved and you are responsible the cost sharing amount. You have been 
asked to pay 20% coinsurance of the allowed amount for the DME provided on April 5, 2022. These 
items/services fall within the durable medical equipment benefit category.  
 
Code Allowed Amount 20% Coinsurance 
E0188 $15.50 $3.10 
E0935 $350.66 $70.13 E0236 $27.61 $5.52 
E0673 $196.85 $39.37 
E0650 $60.22 $12.04 
E0249 $62.15 $12.43 
E0100 $15.47 $3.09 
E0163 $45.51 $9.10 
Total  $154.78 
 
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 coinsurance for the DME provided on April 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the KANJINTI (Q5117), DEXAMETHASONE 
(J1100), FAMOTIDINE (J3490), PERTUZUMAB (J9306), DIPHENHYDRAMINE (J1200), 
ONDANSETRON (J2405). 
 
You asked the Plan to pre-approve the KANJINTI (Q5117), DEXAMETHASONE (J1100), FAMOTIDINE 
(J3490), PERTUZUMAB (J9306), DIPHENHYDRAMINE (J1200), ONDANSETRON (J2405). You say that 
the drugs are medically necessary. The Plan denied your request. The Plan says the member is in a clinical 
study. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the KANJINTI (Q5117), DEXAMETHASONE (J1100), 
FAMOTIDINE (J3490), PERTUZUMAB (J9306), DIPHENHYDRAMINE (J1200), ONDANSETRON 
(J2405) as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. 
Therefore, we decided that the Plan does not have to pre-approve the KANJINTI (Q5117), 
DEXAMETHASONE (J1100), FAMOTIDINE (J3490), PERTUZUMAB (J9306), DIPHENHYDRAMINE 
(J1200), ONDANSETRON (J2405).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve total electric hospital bed. You say that you meet qualifications for a total 
electric hospital bed. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio (J1306). 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee has not tried and failed the preferred 
drug, Praluent (or Repatha for open formularies). 
 
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 did not provide a copy of the applicable Schedule of Cost 
Sharing for this case. We asked for this document, but it was not provided to us. Without this information we 
cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee 
has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not 
substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve 
Leqvio (J1306).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a skilled nursing facility stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the health condition criteria for a SNF 
stay. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on February 25, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you have not been billed for 
ultrasounds in the past and you cannot afford the copayment. 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 $145 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $145 copayment for ultrasound. This item/service falls within the other 
outpatient diagnostic tests 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. However, since the allowed amount is less than the standard copayment, you only owe 
$66.56. Therefore, we decided that the Plan does not have to waive the copayment for ultrasound provided on 
February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 22, 2022.
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 services are necessary to ensure a safe discharge 
home for the enrollee. The Plan denied your request. The Plan says the enrollee could receive care in another 
setting. 
 
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 documentation shows that the enrollee has complex functional impairments and 
active medical issues. The enrollee is documented to have poor tolerability in therapy. The criteria for IRF have 
not been met. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combination use of Keytruda, carboplatin, pemetrexed, 
palonosetron, dexamethasone, and fosaprepitant intravenous (IV). 
 
You asked the Plan to pre-approve drug combination. You say that this is a standard first-line treatment for 
non-small cell lung cancer adenocarcinoma. The Plan denied your request. The Plan says this drug combination 
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 drug combination. Our reviewer says 
that the enrollee does not meet criteria for this requested drug combination. Our physician reviewer found the 
enrollee has progression on pembrolizumab. The requested combination is not Food & Drug Administration 
(FDA) approved for the enrollee's diagnosis. This use is not supported by one of the major drug compendia or 
by clinical research appearing 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 drug combination have not been met. Therefore, we decided that the Plan does 
not have to pre-approve combination use of Keytruda, carboplatin, pemetrexed, palonosetron, dexamethasone, 
and fosaprepitant intravenous (IV).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary. The 
Plan denied your request. The Plan says criteria for LTACH has not been met. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 48 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 61 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the suvmitted records do not document the 
enrollee has cystic fibrosis or bronchiectasis that has been confirmed by a computed tomography (CT) scan or 
one of the qualifying neuromuscular diseases. No qualifying diagnosis for the high frequency chest wall oscillation device has been documented in the available records. The criteria for coverage are not met and the 
services are not reasonable or medically necessary at this time. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Bevacizumab-awwb (Mvasi). 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not supported for metastatic colorectal 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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that the patient has been 
on Lonsurf, and per the provider, it is too early to assess response, with no clear progression. Thus, per the 
compendia, Lonsurf with Mvasi can be approved. Mvasi is allowed past progression, according to studies. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Bevacizumab-awwb (Mvasi).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has failed 
conservative treatment. The Plan denied your request. The Plan says this procedure has been approved at the 
ambulatory level, and if the enrollee experiences any complications reconsideration of inpatient level of care 
can be performed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found there is no documentation provided to support an expectation that the 
enrollee will require a greater than 2 midnight stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to regain previous 
functionality. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization 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 left heart catheterization. Our reviewer 
says that the requested left heart catheterization is not medically necessary. Our physician reviewer found the 
enrollee had a negative radionuclide stress test in 2020. The enrollee has not had chest pain. Documentation 
does not support the rationale for this invasive imaging study. Guidelines do not support a need for cardiac 
catheterization in this setting. As a result, at this time cardiac catheterization 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.