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

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies haven't proven this is helpful for the treatment of your 
condition. 
 
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 Keytruda. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that you have received 
the requested drug for 24 months of treatment. The Food and Drug Administration has not stated that the 
requested drug is indicated for your condition. The Medicare approved cancer drug compendia does not contain 
a supportive citation for the use of the requested drug in your clinical situation. There is no literature from 
Medicare approved cancer journals that were submitted for review. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from March 16, 2022, to April 14, 
2022. 
 You asked the Plan to pay for home health care. You say that you attempted to submit a timely NOA. The Plan 
denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 16, 2022. The NOA was not received by the Plan until July 18, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from March 16, 2022, to April 14, 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 the ventilator. You say that this device is 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
this equipment is not medically necessary. Our physician reviewer found the records do not support that a ventilator is medically necessary. The enrollee's condition could be treated using BiPAP. Records do not show 
a failed trial of this treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you are not a surgical candidate, and 
the pain is severe which limits your ability to move around. The Plan denied your request. The Plan says the 
genicular nerve block is 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
never blocks are considered an experimental technique and is the subject of ongoing clinical trials. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 23, 
2023. 
 You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says payment for 
code 99285 is bundled into payment for code 99291. 
 
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, we have confirmed that code 99285 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 23, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stereotactic Radiosurgery (SRS) (77014, 77372, 
G6002). 
 
You asked the Plan to pre-approve SRS. You say that the enrollee needs treatment to start in order to beat the 
odds. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 SRS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in general, the decision would be favorable for SRS for an enrollee with one brain metastasis 
from small cell lung cancer (SCLC). However, for this enrollee, the only clinical records are a treatment 
planning note and a telephone encounter with no actual clinical information. There is no documentation of 
performance status, magnetic resonance imaging of the brain (there is a comment that enrollee has a 5-
millimeter (mm) lesion in the cerebellum), H and P, extent and control of extracranial disease (which if more 
life threatening than the brain lesion would make SRS likely un-needed). The reviewer suspects that the 
treatment is necessary and would meet the criteria of being furnished in accordance with accepted standards of 
medical practice, but the decision is unfavorable due to lack of demonstration of need. If the information is 
resubmitted and shows good Karnofsky Performance Status Scale (KPS) and control of extracranial disease 
(general criteria that support need of SRS) the decision would likely be favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SRS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stereotactic Radiosurgery (SRS) (77014, 77372, G6002).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 
 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 methotrexate.  
 
Benefits for the medication 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 pay for the acute inpatient hospital care provided from  
August 9, 2022, to August 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says inpatient care was not medically necessary. 
 
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 pay for 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 that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two 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 pay for the acute inpatient hospital care provided from August 9, 2022, to 
August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 14, 2023, billed 
with procedure code 99291. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation provided 
does not include the time spent providing this service. As such, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
February 14, 2023, billed with procedure code 99291.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cyclophosphamide (J9070). 
 You asked the Plan to pre-approve cyclophosphamide. You say that the request is medically necessary. The 
Plan denied your request. The Plan says 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 cyclophosphamide. Our reviewer says 
that the requested drug cannot be recommended. Our physician reviewer found the drug ordered was 
subsequently changed by the provider and the requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred 
step one alternative. Therefore, the elements of the coverage criteria are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cyclophosphamide have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cyclophosphamide (J9070).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute inpatient rehab 
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 enrollee does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 11047 billed for date of service April 24, 
2023.  
 
You asked the Plan to pay for procedure code 11047. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 11047 is 10. The MAI value for this code is 3. You billed 17 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 11047 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 11047 billed for date of service April 24, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 1, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on December 1, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transfer bench for tub or toilet with or without commode 
opening (E0247) provided February 20, 2023. 
 
You asked the Plan to pay for a transfer bench. You say that please review the attached documents to show the 
enrollee requires this item. Please reconsider processing. The Plan denied your request. The Plan says bathtub 
seats are considered a convenience item and hygienic equipment and not primarily medical in nature. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a transfer bench for tub or toilet with or without commode 
opening (E0247) provided February 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74176). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. The Plan denied your request. The 
Plan says the provider did not say why pictures of the enrollee's pelvis are needed. The Plan also says that a 
picture of the enrollee's abdomen may be better for their condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is not medically reasonable and necessary. Our 
physician reviewer found the enrollee was found to have incidental left adrenal nodule on myocardial positron 
emission tomography (PET) perfusion scan and a CT was recommended. Our reviewer also found that the 
request for a scan to include the pelvis is not reasonable. 
 
 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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74176).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular nerve ablation. 
 
You asked the Plan to pre-approve left knee genicular nerve ablation. You say that the requested left knee 
genicular nerve ablation is medically necessary.  The Plan denied your request. The Plan says the requested left 
knee genicular nerve ablation is 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 left knee genicular nerve ablation. Our 
reviewer says that the requested left knee genicular nerve ablation is not medically necessary. Our physician 
reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the left knee. He presented 
with left knee pain. The left knee exam reveals a range of motion of 5-130. There is moderate patellar mobility 
with some discomfort. Severe medial and moderate lateral joint line tenderness.  
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. He is noted to have had a genicular nerve block; however, 
no other conservative treatments are noted. Additionally, there are no formal diagnostic studies provided to 
corroborate the pathology of the left knee. Moreover, there is a lack of large-volume, long-term peer-reviewed 
outcome studies to support the use of these procedures for this enrollee as discussed above. Therefore, the 
requested left knee genicular nerve ablation 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 left knee genicular nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve left knee genicular nerve ablation.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen with and 
without dye.  
You asked the Plan to pre-approve the MRI of the abdomen. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that they cover services that 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 of the abdomen. Our reviewer 
says that the MRI is medically necessary. Our physician reviewer found the most frequent site of metastasis is 
the liver. Other sites include the lungs, skin/soft tissue, and bones. For enrollee's who elect to have surveillance 
imaging, options include a contrast-enhanced MRI or ultrasound of the liver, with modality preference 
determined by expertise at the treating institution. Additional imaging modalities may include chest/ 
abdomen/pelvis a computerized tomography (CT) scan with contrast, or a dual energy subtraction chest x-ray. 
 
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 of the abdomen have been met. Therefore, we decided that the Plan has 
to pre-approve a magnetic resonance imaging (MRI) of the abdomen with and without dye.  
 
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.