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

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under pressure, full body 
chamber, per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen 
therapy per session (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance/supervision. 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 follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to the following 
conditions. 
 
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 HBO therapy and physician 
attendance/supervision. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found hyperbaric oxygen therapy is considered not medically necessary. This enrollee has had a 
nonhealing foot wound with chronic osteomyelitis, following a bunionectomy more than a year ago.  Treatment 
has consisted of debridement and antibiotic therapy, with infectious diseases consultation. Medicare criteria for 
hyperbaric oxygen therapy include "chronic refractory osteomyelitis, unresponsive to conventional medical and 
surgical management."  However, conventional management would be expected to include assessment of 
adequacy of circulation in the affected area, and efforts at smoking cessation. Neither of these is documented in 
the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance/supervision have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) under pressure, 
full body chamber, per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric 
oxygen therapy per session (99183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a home mechanical ventilator.  
You asked the Plan to pre-approve continued coverage of a home mechanical ventilator. You say that the 
documentation provided supports the need for the item in dispute. You say that medical necessity was 
previously established under an authorization with the Plan. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the continued use of a ventilator is covered when 
specific criteria have been met.  
 
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 continued coverage of a home 
mechanical ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician 
reviewer found the ventilator was provided in June of 2022 and there was a medical follow-up note from 
November 2, 2022. The provided records do not clearly document progress of relevant symptoms with use of 
the ventilator. The provided records do not document an average of 4 hours per 24-hour period by the time of 
re-evaluation. The records document an average daily use of 12 minutes from December 28, 2022, through 
January 26, 2023. In addition, the records do not document a signed and dated statement completed by the 
treating practitioner no sooner than 61 days after initiating use of the device, declaring that the beneficiary is 
compliantly using the device and that the beneficiary is benefitting from its use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued coverage of a home mechanical ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued coverage of a home mechanical 
ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detox treatment with a non-participating 
provider. 
 
You asked the Plan to pre-approve inpatient detox treatment. You say that you called to verify benefits but later 
found that the recovery center does not accept Medicare plans. The Plan denied your request. The Plan says the 
requested provider is not a Medicare facility and does not take Medicare. Your plan requires the requested 
services to be obtained from eligible mental health and/or substance abuse providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve inpatient detox treatment with a 
non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has a history of chronic respiratory failure from chronic obstructive pulmonary 
disease with acute exacerbation in July 2022. No recent records are provided. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for weakness, COVID 19 and rhabdomyolysis. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 Nivolumab and Ipilimuma. 
 
You asked the Plan to pre-approve Nivolumab and Ipilimuma. You say that Nivolumab and Ipilimuma are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Nivolumab and Ipilimuma. Our 
reviewer says that this drug combination is not medically necessary. Our physician reviewer found records 
show prior progression on immunotherapy. This chemotherapy combination is not supported in this clinical 
setting by the Medicare-approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab and Ipilimuma have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Nivolumab and Ipilimuma.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), harness 
(E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve a power seat elevation system, electronic connection between wheelchair 
controller and two or more power seating system motors, harness, and expandable controller. You say that the 
power recline makes the chair medically necessary for the enrollee. The Plan denied your request. The Plan 
says the requested items do not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 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 power seat elevation system, 
electronic connection between wheelchair controller and two or more power seating system motors, harness, 
and expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested power seat elevation feature 
is statutorily non-covered as it serves no primary medical purpose. Our reviewer also found that the provided 
records document that the enrollee has 3+ out of 5 left upper extremity strength with "100%" left hand range of 
motion and "good" left hand coordination, thus indicating they have adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seat elevation system, electronic connection between wheelchair 
controller and two or more power seating system motors, harness, and expandable controller have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300), 
electronic connection between wheelchair controller and two or more power seating system motors (E2311), 
harness (E2313), and expandable controller (E2377).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gelsyn knee hyaluronan injection. 
 
You asked the Plan to pre-approve a Gelsyn knee hyaluronan injection. You say that your doctor offered this 
injection and nothing other than that. You also say that you were never offered any other drug, and you cannot 
do the surgery. The Plan denied your request. The Plan says you have not tried Euflexxa. 
 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 a Gelsyn knee hyaluronan injection. 
Our reviewer says that Gelsyn knee hyaluronan is not medically reasonable and necessary. Our physician 
reviewer found the provided records do not indicate that you have tried and failed the Plan's preferred step one 
alternative. The record does not indicate that you have a contraindication to, or would have an adverse effect 
from the Plan's preferred step one alternative. Our reviewer found that 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 a Gelsyn knee hyaluronan injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Gelsyn knee hyaluronan injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and occupational therapy 
services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that you require additional skilled rehabilitation services to provide treatment 
that is medically necessary. You do not require additional skilled rehabilitation services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
your condition and/or prevent deterioration. Our reviewer also found that you have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy and occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve superficial radiation therapy with ultrasound guidance, 
total of 20 treatments. 
 
You asked the Plan to pre-approve superficial radiation therapy with ultrasound guidance. 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 superficial radiation therapy with 
ultrasound guidance. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found certainly using ultrasound on a daily basis 
is not unreasonable to offer but not necessary. The device itself is FDA approved for use with ultrasound 
though that in and of itself does not mean that daily imaging is necessary but simply that the device was 
designed to incorporate this functionality. Therefore, to bill for daily simple simulations and/or Image guided 
radiotherapy (IGRT) for a technology for which need has not been established by published data or supported 
by consensus guidelines is not necessary. Billing for daily IGRT which would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of superficial radiation therapy with ultrasound guidance have not been met. 
Therefore, we decided that the Plan does not have to pre-approve superficial radiation therapy with ultrasound 
guidance, total of 20 treatments.
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 the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with altered mental status secondary to sepsis in the setting of acute kidney injury and respiratory 
failure. The record indicates that the enrollee is still acutely ill with pneumonia and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag. 
 
You asked the Plan to pre-approve Opdualag. You say that the records provided support the need for the drug 
in dispute. The Plan denied your request. The Plan says the requested drug is only FDA approved for 
unresectable or metastatic cutaneous melanoma. The Plan says that the study used as evidence of FDA-
approval specifically excluded patients with uveal melanoma. 
 
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 Opdualag. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found uveal melanoma patients were excluded 
from the FDA's trial of the drug. Our physician reviewer found that Opdualag is not medically necessary for the 
enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdualag have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdualag.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is insufficient prospective, long-term, clinical data available to 
determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to 
external beam radiation therapy, intensity-modulated radiation therapy (IMRT), or brachytherapy with regards 
to safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee is not able to tell when blood sugar is low. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).