Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
is not showing threat to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 The file shows that continued inpatient services from May 9, 2023, were requested. 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 services Our physician reviewer found that the enrollee 
was admitted with recurrent, severe, major depressive disorder without psychotic features. It did not appear that 
active treatment was taking place. The services were not reasonably expected or medically necessary to 
improve the enrollees condition or for the purpose of diagnosis. This enrollee does not meet the criteria and 
could be treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, 
auditory or visual hallucinations, delusions, and was not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety.  
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient mental health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee does not 
have an accepted medical indication for the requested use. 
 
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 physician reviewer 
found that the enrollee has non-small cell lung cancer. The requested use of Keytruda is not FDA approved for 
the enrollee's diagnosis as there has been no ALK or EGFR testing. The requested use is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic services provided on October 31, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the services billed do not meet 
Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support the denial of 
the services. It is the burden of the Health Plan to substantiate their decision with evidence. In this case, the 
Plan's denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has 
to pay for chiropractic services provided on October 31, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 84100, 83540, 82728, and 
83550) related to end-stage renal disease (ESRD) provided on November 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 84100, 83540, 82728, and 83550) related to end-stage 
renal disease (ESRD) provided on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540, 83550, and 
83970) related to end-stage renal disease (ESRD) provided on November 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540, 83550, and 83970) related to end-stage 
renal disease (ESRD) provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the Volara will greatly improve her bronchial 
drainage. The Plan denied your request. The Plan says the device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our physician reviewer 
found that the enrollee has chronic obstructive pulmonary disease (COPD) with chronic cough. There is a listed 
diagnosis of bronchiectasis, but the most recent chest computed tomography (CT) scan makes no mention of 
bronchiectasis in the report. There is no previous CT scan that documents bronchiectasis. The enrollee has been 
using a flutter valve and, according to one of the progress notes, it has a high-frequency chest wall oscillation 
vest at home. The Volara device includes 3 components, positive end expiratory pressure, nebulization of 
medications, and intra-airway oscillation. There is inadequate evidence that this device provides better or 
equivalent airway clearance than other devices, or that it is safe and effective in the treatment of COPD as an 
outpatient. Nebulization of medications would represent a duplication of services already provided. Therefore, 
the Volara system is not 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the requested IRF admission is not medically necessary. 
 
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 the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee is currently medically stable at home and has not had a recent acute change in function or neurological 
status. The enrollee does not require the intensity of rehabilitation physician oversight provided in the acute 
inpatient rehabilitation setting. The enrollee does have a stage II sacral pressure wound, but this does not 
necessitate acute inpatient rehabilitation. The enrollees medical and rehabilitation needs do not require the 
intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Currently, the enrollee is dependent for bed mobility 
and transfers and is non-ambulatory. The enrollee has had a progressive decline in function but continues to be 
non-ambulatory and dependent for transfers since being discharged from a skilled nursing facility in August of 
2022. The enrollee may benefit from therapy and assistance but does not require the intensity of therapies 
provided in an IRF and it is unclear that he can tolerate this intensity of therapy. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an automatic blood pressure monitor (A4670) 
purchased on December 8, 2022. 
 
You asked the Plan to reimburse you for an automatic blood pressure monitor. You say that you thought this 
would be covered. The Plan denied your request. The Plan says this is not covered because it is 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 reimburse you for an automatic blood pressure monitor (A4670) 
purchased on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540 and 83550) 
related to end-stage renal disease (ESRD) provided on September 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540 and 83550) related to end-stage renal 
disease (ESRD) provided on September 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional home care physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary for the enrollee. 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 that the 
enrollee does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning 
at a level commiserate with a lower level of care (i.e., home exercise program, outpatient therapy, layperson 
supervision). The enrollee lives in a supervised setting.  As such, the requested, ongoing, home health physical 
therapy services are not medically necessary or 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional home care physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried 
and failed Monovisc, Orthovisc, Synvisc, or Synvisc One. The documentation does not support that Monovisc, 
Orthovisc, Synvisc, or Synvisc One would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (codes 82728, 83540, and 83550) 
related to end-stage renal disease (ESRD) provided on November 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these codes are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (codes 82728, 83540, and 83550) related to end-stage renal 
disease (ESRD) provided on November 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apligraf services. 
 
You asked the Plan to pre-approve Apligraf services. You say that the enrollee has now had the lab work done 
and the results support the need for Apligraf services. You say that the clinical documentation provided 
supports medical necessity. The Plan denied your request. The Plan says the records do not show that the 
enrollee has failed attempts at conservative wound therapy for 30 days, including proper diabetic treatment. 
The Plan says that the requested 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 Apligraf services. Our reviewer says 
that Apligraf services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has lower extremity venous insufficiency wound. The record provided indicates that the wounds are decreasing in size over a less than thirty-day period.  The record 
provided indicates that the enrollee is not in glycemic control. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Apligraf services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Apligraf services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alimta. 
 
You asked the Plan to pre-approve Alimta. The Plan denied your request. The Plan says the documentation 
does not support the requested use. 
 
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 Alimta. Our physician reviewer found 
that the enrollee has metastatic adenoid cystic carcinoma. The requested use of Alimta is not FDA approved for 
the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal as there is no recent trial as monotherapy. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary 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 Alimta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Alimta.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the enrollee would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an MRI of the 
lumbar spine 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 lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically necessary. Our physician reviewer found that 
during the most recent encounter on April 18, 2023, there were no neurological abnormalities, numbness or 
tingling described, although reflexes were not tested. There is mention of an MRI of the lumbar spine a few 
years ago but there is no report in the records. Plain films of the lumbar spine have not been done and no 
conservative treatment such as physical therapy has been prescribed. Therefore, the medical necessity of the 
requested MRI of the lumbar spine has not been established in the submitted records. 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 lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is asymptomatic. 
 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 requested services. Our physician 
reviewer found that the enrollee has no cardiovascular symptoms. There is no documentation that the 
electrocardiograph shows an uninterpretable pattern. There is no evidence provided that would support the need 
for stress echocardiography. There is insufficient documentation to support the medical necessity for the 
requested stress echocardiography in this enrollees clinical management. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transthoracic echocardiography services.