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

 
We decided that the Plan does not have to pre-approve Trastuzumab-anns (Kanjinti) (Q5117) to be used in 
conjunction with Fluorouracil, Leucovorin, and Oxaliplatin. 
 
You asked the Plan to pre-approve Trastuzumab-anns. You say that the enrollee has esophagus cancer, and 
their HER2 score is 1+. The Plan denied your request. The Plan says there was no support for Trastuzumab-
anns (Kanjinti) for treatment of HER2-negative stage IV metastatic esophageal adenocarcinoma. 
 
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 Trastuzumab-anns. Our reviewer says 
that Trastuzumab-anns 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 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 Trastuzumab-anns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Trastuzumab-anns (Kanjinti) (Q5117) to be used in conjunction with Fluorouracil, 
Leucovorin, and Oxaliplatin.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fluorouracil. 
 
You asked the Plan to pre-approve Fluorouracil. 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 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 Fluorouracil. Our reviewer says that the 
services are medically necessary. Our physician reviewer found venous infusion of 5-FU may provide 
significant palliative effect for some enrollees with symptomatic, refractory carcinoma of the prostate. 
Although this does not meet compendia and is not fda approved will be approved per literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fluorouracil have been met. Therefore, we decided that the Plan has to pre-
approve Fluorouracil.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic 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 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex, Bortezomib, Dexamethasone, 
Methylprenisolone sodium, and Diphenhydramine HCL. 
 
You asked the Plan to pre-approve Darzalex, Bortezomib, Dexamethasone, Methylprenisolone sodium, and 
Diphenhydramine HCL. 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 Darzalex, Bortezomib, Dexamethasone, 
Methylprenisolone sodium, and Diphenhydramine HCL. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the proposed combination is FDA approved for the treatment of 
relapsed or refractory multiple myeloma (in combination with dexamethasone and bortezomib) in adults who 
have received at least 1 prior therapy. For 1st line therapy treatment of newly diagnosed multiple myeloma (in 
combination with bortezomib, melphalan, and prednisone) in adults who are ineligible for autologous stem cell 
transplant. The proposed regimen does not include melphalan. Combination is also not supported by the NCCN 
Guidelines. The service is 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 Darzalex, Bortezomib, Dexamethasone, Methylprenisolone sodium, and 
Diphenhydramine HCL have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Darzalex, Bortezomib, Dexamethasone, Methylprenisolone sodium, and Diphenhydramine HCL.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a skilled nursing facility admission is medically 
necessary for the member. The Plan denied your request. The Plan says medical records show a SNF admission 
is not medically necessary and required services can be safely provided at a different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says admission to the LTACH is not medically necessary 
and continued acute hospital stay was offered until the member could be discharged to a lower level of care. 
 
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. All medically necessary care is being provided in the 
current acute care setting and the health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vitamin D assay (82306) provided on August 15, 
2022. 
 
You asked the Plan to pre-approve the laboratory service. You say that you were not aware that this was not a 
covered expense. The Plan denied your request. The Plan says the laboratory service was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pre-
approve a vitamin D assay (82306) provided on August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service July 2, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This 
means that no TC billing is recognized because payment for the underlying clinical laboratory test is made to 
the hospital, generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT 
code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 85060 billed for date of service July 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. The Plan denied your request. The Plan says this 
enrollee will be using the home mechanical ventilator in a bilevel positive airway pressure (BiPAP) mode and 
therefore the denial is correct. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has chronic hypercapnic respiratory failure from chronic obstructive 
pulmonary disease. The record indicates that the enrollee was successfully treated with BiPAP and that BiPAP 
was ordered. Our reviewer found that the provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with average volume-assured pressure support (AVAPS) capability. Our physician reviewer 
also found that the Plan has indicated coverage for such a device is available upon request. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
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 you were independent with mobility and activities of 
daily living prior to your admission. You say that your goal is to return home. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and your needs can be met at an alternate level of 
care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of air ambulance services (A0431, A0436) 
provided on May 24, 2022. 
 
You asked the Plan to pay for air ambulance services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a second unit of service was medically 
unlikely and unnecessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer says 
that the air ambulance services at issue were not medically reasonable and necessary in this case. Our physician 
reviewer found that the available documentation does support that the enrollee suffered from an illness or 
injury that contraindicated transportation by any means other than ambulance. The documentation does support 
that the transferring hospital did not have adequate facilities to provide the medical services needed by the 
enrollee. However, the documentation does not support that the enrollee's condition was such that the time 
needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the 
enrollee's survival or seriously endangered the enrollee's health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for a second unit of air ambulance services (A0431, A0436) provided on May 24, 2022.
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 due to the complexity of the enrollee 
they will continue to require acute care for a period of time before they will be safe enough to transition. You 
say that at an LTACH the enrollee's needs will be met daily and they will continue to manage the enrollee's 
other medical issues confidently. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 health 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. The Plan denied your request. The Plan says the 
medical records provided do not indicate that the member meets the diagnostic criteria of both Alzheimer's 
disease and frontotemporal dementia. There is no indication that the exam is being requested in the context of a 
clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan of the brain. Our reviewer 
says that the enrollee does not meet the criteria for coverage for a PET scan of the brain. Our physician 
reviewer found the enrollee has shunt in place for normal pressure hydrocephalus. Cognitive impairment has 
been documented with Montreal Cognitive Assessment (MoCA) score of 16/30. Our reviewer found there is no 
documentation of any behavioral issues to suggest FTD. Our physician reviewer also found that per the Centers 
for Medicare & Medicaid Services (CMS) NCD rules, a PET/computed tomography (CT) of the brain will only 
be approved if there are clinical features of both AD and FTD, and such is not the case for this individual.  
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).