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

 
We decided that the Plan has to pre-approve Zarxio. 
 
You asked the Plan to pre-approve Zarxio. You say that the services are necessary. The Plan denied your 
request. The Plan says that 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 Zarxio. Our reviewer says that the 
services are medically necessary. Our physician reviewer found guidelines for the use of Lonsurf for toxicity 
for neurtropenia recommend dose reduction and potentially the use of growth factors. This enrollee has severe 
neutropenia and is heavily pretreated. The use of zarxio is reasonable and medically necessary for the 
prevention of neutropenic fever. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zarxio have been met. Therefore, we decided that the Plan has to pre-approve 
Zarxio.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on May 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more appropriate code to use in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 62326 is "Injection(s), including indwelling catheter 
placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or 
subarachnoid, lumbar or sacral (caudal); without imaging guidance." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
describe injection including indwelling catheter placement, and therefore cannot be verified.  Operative report 
documents "Injection technique: single-shot." In this case, CPT 62326 cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF. You also 
say that the enrollee will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level 
of care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an 
IRF. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patients 
medical conditions appear stable with no issues that appear to require a physicians evaluation three or more 
times per week. 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 acute IRF admission and services.
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. 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 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 the services are not medically necessary. Our physician reviewer found as the provided records do not 
clearly document that this enrollee has neuromuscular disease, thoracic restrictive disease or chronic 
respiratory failure consequent to chronic obstructive pulmonary disease, the ventilator at issue does not meet 
Medicare criteria for medically necessary and reasonable for this enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camzyos. 
 
You asked the Plan to pre-approve Camzyos. The Plan denied your request. The Plan says Camzyos 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 Camzyos.  
 
Benefits for Camzyos 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says these studies are to be used very selectively. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that it is a valid contention that patients with a greater than 20% lifetime risk of breast cancer should be offered MRI breast 
screening exams. This patient's record states she has a greater than 21% lifetime risk and if true the request for 
annual MRI is valid and should be honored. The problem in this case is that the model for the calculation of 
such lifetime risk is not included in the materials submitted. The two most common accepted models are the 
Gail Risk Model and the Tyler-Cuzick models. In order to validate the medical necessity for the requested MRI 
the method of lifetime risk calculation should be included in the clinical materials. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the breast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InSpace balloon. 
 
You asked the Plan to pre-approve these services. 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is limited published, large-
scale/volume, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment 
for the enrollees pathology. The peer-reviewed literature does not demonstrate significant benefits with the use 
of the InSpace balloon versus an arthroscopic procedure alone. Further studies are needed. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested InSpace balloon for the approved shoulder arthroscopy, in 
this case, is not medically reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an InSpace balloon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lens (V2781), ultraviolent lens (V2755), anti-
reflective coating per lens (V2750) and a tine photochromatic per lens (V2744) provided on July 15, 2022.  
You asked the Plan to pay for progressive lens (V2781), ultraviolent lens (V2755), anti-reflective coating per 
lens (V2750) and a tine photochromatic per lens (V2744). You say that you have insurance, and the insurance 
should pay for your services. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 for eyeglasses (frames and lenses) or up to $200 for contact lenses every 
two years. 
 
We looked at the file and the Plan's rules. The Plan only covers up to $200 for eyeglasses (frames and lenses) 
every two years. This means you are responsible for any cost over the $200. In this instance, you are 
responsible for $664. Based on this information, we decided that the Plan's rules for coverage of progressive 
lens (V2781), ultraviolent lens (V2755), anti-reflective coating per lens (V2750) and a tine photochromatic per 
lens (V2744) have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens 
(V2781), ultraviolent lens (V2755), anti-reflective coating per lens (V2750) and a tine photochromatic per lens 
(V2744) provided on July 15, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vabysmso. 
 
You asked the Plan to pre-approve Vabysmso. You say that this is medically necessary. The Plan denied your 
request. The Plan says that step therapy requirements have not been met. 
 
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 Vabysmso. Our reviewer says that 
although the Plan's step therapy rules require a trial of Avastin before they will approve Vabysmso, step  
therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not 
actively receiving the affected medication. It is documented on October 13, 2022, that the enrollee is being 
treated with Vabysmo. The enrollee received a 6 mg injection of Vabysmo on that date.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmso have been met. Therefore, we decided that the Plan has to pre-
approve Vabysmso.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have blood clots. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device and related supplies 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 a radiofrequency ablation procedure (64635). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint ablation procedures are covered after the 
patient has had at least two (2) medically reasonable and necessary diagnostic Medial Branch Blocks, with each 
one providing a consistent minimum of 80% sustained relief of primary (index) pain. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that this procedure is not medically necessary. Our physician reviewer found the records 
show that the enrollee has had only 1 set of diagnostic injections. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine. 
 
You asked the Plan to pre-approve an MRI of the lower spine. You say that an MRI is medically necessary for 
your doctor to evaluate the injury, which is affecting your ability to walk. The Plan denied your request. The 
Plan says an MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lower spine. Our 
reviewer says that an MRI of the lower spine is not medically necessary. Our physician reviewer found that you 
have left sciatica and painful pressure over left sciatic notch. Plain films show trace anterolisthesis. 
Neurological exam revealed no gait disturbance. Reflexes and remainder of usual neurological exam are not in 
the submitted records. There are no red flags to preclude a 6-week trial of physical therapy to determine 
medical necessity of requested MRI lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lower spine.
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. 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 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 the services are not medically necessary. Our physician reviewer found this enrollee has chronic 
obstructive pulmonary disease (COPD) and was recently hospitalized with acute respiratory failure. Arterial 
blood gases (ABG) was consistent with acute on chronic hypercarbic respiratory failure. The enrollee may 
benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) 
during sleep as an outpatient. But 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Travatan. 
 
You asked the Plan to pre-approve Travatan. The Plan denied your request. The Plan says Travatan 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 Travatan.  
 
Benefits for Travatan 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: 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 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. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted with acute hypoxic respiratory failure in the setting of multilobar pneumonia and chronic medical 
conditions. The record indicates that the enrollee is improving but still require acute care services before 
transitioning to a lower level of care. 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 she is not currently 
receiving but that would be available at the LTACH facility. The LTACH services are not reasonable or 
medically 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 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.