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

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that The enrollee's chronic respiratory failure was 
previously treated with oxygen therapy, inhaled steroids, and bronchodilators, but now he requires a non-
invasive ventilator. The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in AVAPS mode that could be delivered by BiPAP is not covered. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has COPD with recurrent hospital admissions for hypercarbic respiratory failure, and arterial blood gases is consistent with acute-on-chronic CO2 retention. The enrollee has bilevel positive 
airway pressure (BiPAP) at home but is not able to use it consistently. There is no evidence of failure of BiPAP 
as an outpatient. If the enrollee is unable to use BiPAP, it seems unlikely the enrollee will be able to use a 
home ventilator, given the same noninvasive interface. The enrollee may benefit from BiPAP with average 
volume-assured pressure support, and effort to improve acceptance.  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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebroplasty (22511). 
 
You asked the Plan to pre-approve a percutaneous vertebroplasty. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. The rules say that PVA is covered in patients who meet the criteria listed 
in the Medicare rules section of this letter. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation is not evident in the case record regarding an 
acute or subacute osteoporotic VCF at T1-L5 by recent (within 30 days) advanced imaging. 
 
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 percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous vertebroplasty (22511).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lympha Press pneumatic compression device to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that the Plans in-network 
providers cannot provide the requested item. You say that the requested provider is the only provider of the 
specific device. The Plan denied your request. The Plan says you requested a brand-specific item and there is 
no documentation to support that the enrollee is in need of specialized services that are not available through 
using a pneumatic compression device from an in-network provider. Furthermore, the Plan says that there are 
in-network providers within a reasonable distance from the enrollees location that can provide the requested 
services. 
 
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 
a Lympha Press pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
additional services are not covered at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that the Plan has agreed to pre-approve 30 days of 
treatment. The rules say that wounds must be evaluated at least every 30 days during the administration of 
hyperbaric oxygen therapy.  
 Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional hyperbaric oxygen therapy services at this time.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 12, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
12, 2021.
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 the services requested are medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device is unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Coflex device is experimental. More research is needed to show safety and efficacy of 
the device. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that you are worried about the micro nodules found 
and would like a repeated CT chest scan in 5-month intervals. The Plan denied your request. The Plan says a 
follow-up CT scan was recommended at 12 months and the services is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
CT scan of the thorax is not medically needed at this time. Our physician reviewer found that this enrollee has 
asthma, and a chest CT was done June 9, 2022, because of a cough. This showed several nodules, all 4 
millimeters or less. The enrollee is a non-smoker, but there is no indication of whether the enrollee smoked in 
the past. If the patient is a never-smoker and low risk for cancer, no follow-up imaging is needed. A follow-up 
at 12 months could be considered and would be reasonable. The denial of the CT scan at 5 months is upheld. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the thorax.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the face. 
 
You asked the Plan to pre-approve the CT scan. You say that there is a broken bone in your face and a CT scan 
is medically necessary. The Plan denied your request. The Plan says the records from the enrollee's provider 
did not state why the CT scan was medically necessary and the x-ray was not sufficient; therefore, the CT scan 
cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that the 
CT scan of the face is not medically needed at this time. Our physician reviewer found that this enrollee was 
last evaluated clinically 5 months ago. It cannot be determined from the notes provided what the enrollees 
current symptoms are related to her face. Importantly the initial notes do not describe visual changes although 
there is a submitted photo from that time showing left periorbital ecchymosis. Without recent clinical 
evaluation and/or plain x-rays the medical necessity for the requested CT scan of the face cannot be 
determined. 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the face.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva (denosumab) (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one of the preferred 
drugs, intravenous pamidronate or zoledronic acid. 
 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 Xgeva. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed any of the preferred drugs. The reviewer also found that there is no 
documentation provided indicating that the plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (denosumab) (J0897).
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 needs rehabilitation to regain strength. 
The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program? There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 not getting this treatment will worsen your ability to 
process food and lower your quality of life. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested IRF services 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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 IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system (33289, C2624). 
 
You asked the Plan to pre-approve the CardioMEMS system. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of clinical studies examining long-term 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 patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS system (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutrition. 
 
You asked the Plan to pre-approve enteral nutrition. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral nutrition.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning wedge pillow. 
 
You asked the Plan to pre-approve a positioning wedge pillow. The Plan denied your request. The Plan says 
this pillow is not primarily medical in nature. 
 
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 positioning wedge pillow.
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 medically necessary. The Plan denied 
your request. The Plan says records indicate that the enrollee has minimal deficits and require minimum 
assistance with activities of daily living. The enrollee's needs can be met at a lower level of care, such as a 
skilled nursing facility. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. 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 pembrolizumab. 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 pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.