Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve drug test(s) (G0480). 
 
You asked the Plan to pre-approve drug test(s). You say that medical necessity is supported for the requested 
service. The Plan denied your request. The Plan says that there is no unexpected screening test for drugs in the 
record to justify a quantitative drug test. The Plan also says there are no concerning symptoms or signs of 
misuse noted in the record, and the test to see how much exactly of each drug is in the enrollee's system is not 
needed to help guide their care. 
 
The Plan follows Medicare rules. Medicare rules say that criteria to establish medical necessity for drug testing 
must be based on patient-specific elements identified during the clinical assessment, and documented by the 
clinician in the patients medical record and minimally include the elements as 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 drug test(s). Our physician reviewer 
found the enrollee has an increased opioid risk score documented and therefore, more definitive testing is 
indicated. Our reviewer found that the request is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug test(s) have been met. Therefore, we decided that the Plan has to pre-
approve drug test(s) (G0480).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is a preventative test that is 
approved by Medicare. The Plan denied your request. The Plan says the Medicare guidelines were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found that the enrollee was diagnosed with 
paranoid schizophrenia, leg swelling, rheumatoid arthritis, obesity, hypothyroidism, peripheral vascular 
disease, and headaches. An incidental benign-appearing cyst in their kidney was identified on ultrasound. A 
computerized tomography (CT) of the abdomen was recommended by their physician to follow-up on this 
finding. A whole-body PET scan was requested by the enrollee. However, the provided documentation did not 
reveal any evidence from history, physical findings, or labs to suggest malignancy to justify PET scan at this 
time. Also, there were no CT results showing suspicious findings. The enrollee does not have an indication for 
which a PET Scan can be covered 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 Day sensor. You say that you are currently using the 
requested product and you meet all requirements for coverage. The Plan denied your request. The Plan says 
you are injecting insulin twice per day, and you must have an insulin regimen that requires frequent dosage 
adjustments. None of these requirements were validated by the prescriber. You do not meet criteria for 
approval of the requested CGM. 
 
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 you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 Day 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
14 Day sensor.
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 given the enrollee's age, frailty, and prior 
good tolerance of single agent Pembrolizumab, you request the enrollee be approved for continued treatment 
with the same regimen. The Plan denied your request. The Plan says Pembrolizumab 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 Pembrolizumab. Our reviewer says that 
Pembrolizumab is not reasonable and necessary for the enrollee. Our physician reviewer found the FDA 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 specific 
clinical situation. Our reviewer found no literature from Medicare approved cancer journals were submitted for 
review. The elements of the coverage criteria are not satisfied. Our physician reviewer also found that 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service 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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current 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 the LTACH services have not been met. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care 
hospital (LTACH) services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous immune globulin (IVIG). 
 
You asked the Plan to pre-approve IVIG. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that IVIG is indicated for lymphoid Leukemia with either 
hypogammaglobulinemia or recurrent bacterial infections.  
 
Review of the file shows that the Plan uses LCD L39314 to support their denial. This LCD is for off-label uses 
for IVIG. Our review has determined that the enrollee has a diagnosis that is FDA-approved and supported by 
Medicare major compendia. Therefore, we disregarded the LCD cited by the Plan. 
 
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 IVIG. Our reviewer says that the 
documentation does support that the requested services are medically reasonable and necessary. Our physician 
reviewer found the enrollee has a diagnosis of chronic lymphocytic leukemia with hypogammaglobulinemia 
and recurrent sinonasal infections and a history of left-hand cellulitis. Based on the medical records provided 
and the Medicare-approved major drug compendia there is documentation that the intravenous immune 
globulin at issue in this case meets Medicare criteria for medically reasonable and necessary and safe and 
effective for the enrollee. intravenous immune globulin is indicated for "Lymphoid Leukemia with either 
hypogammaglobulinemia or recurrent bacterial infections." The Medicare-approved major drug compendia 
support that immune globulin is indicated to prevent bacterial infections in patients with 
hypogammaglobulinemia or recurrent bacterial infections associated with B-cell chronic lymphocytic 
leukemia. Therefore, the enrollee meets criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IVIG have been met. Therefore, we decided that the Plan has to pre-approve 
intravenous immune globulin (IVIG).  
 
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 care 
 
You asked the Plan to pre-approve acute inpatient hospital care. The Plan denied your request. The Plan says 
the planned procedure is currently approved as an ambulatory procedure. The Plan also says there is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 
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 payment are met in this 
case. Our physician reviewer found the enrollee was approved for an elective right total shoulder arthroplasty 
procedure. This is a request for inpatient services following this procedure. Our reviewer found that the 
provided notes did not describe the enrollee with an unstable condition or with an expected complication that 
would require inpatient services for this typically ambulatory procedure. Our physician reviewer also found 
that it is not expected that the enrollee will require hospital services that would likely cross 2 midnights. 
 
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 care
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 enrollee is medically stable and 
needs to be transferred to an LTACH as they will require a multi-disciplinary approach for an extended period 
of time. The Plan denied your request. The Plan says criteria for admission to the LTACH have 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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol Tartrate. 
 
You asked the Plan to pre-approve Arformoterol Tartrate. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Arformoterol Tartrate. Our reviewer 
says that the documentation does not support that the requested drug meets step therapy criteria. Our physician 
reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease. The documentation does 
not support that the enrollee has tried and failed Perforomist (formoterol). The documentation does not support 
that Perforomist (formoterol) would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arformoterol Tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol Tartrate.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 6, 2022, to July 
5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 6, 2022, to July 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components, and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro device. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is not enough medical evidence that shows the MyoPro is reasonable 
and necessary to improve the function of the enrollee's left arm. 
 
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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components, and accessories, custom 
fabricated (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mavenclad. 
 
You asked the Plan to pre-approve Mavenclad. You say that with the enrollee's age and condition, it is your 
opinion that Mavenclad is the most appropriate Multiple Sclerosis medication for them, and is medically 
necessary. The Plan denied your request. The Plan says Mavenclad is a self-administered drug, and does not 
fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mavenclad.  
 
  Benefits for Mavenclad 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) panel 
(87481, 8779) provided on April 20, 2022 
 
You asked the Plan to pay for the infectious disease PCR panel. You say that this panel medically necessary. 
The Plan denied your request. The Plan says PCR testing is not indicated as the following are appropriate 
means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 pay for the infectious disease PCR panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the provided records document a description of the advantages of the 
polymerase chain reaction panel for the identification of fungal infections, but the records do not clarify why 
the testing was mandatory for this enrollee at this time as opposed to standard methods of identifying and 
culturing fungal species. Provided records do not clarify what unique characteristics of this enrollee required 
the more rapid results of the polymerase chain reaction panel or what therapeutic decisions would be made by 
use of the panel as opposed to traditional fungal identification methods.  
 
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 infectious disease PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the infectious disease polymerase chain reaction (PCR) panel (87481, 8779) 
provided on April 20, 2022