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

 
We decided that the Plan does not have to pre-approve Velcade (J9041). 
 
You asked the Plan to pre-approve Velcade. You say that the enrollee's diagnosis was confirmed with a bone 
marrow biopsy. You say the enrollee had a positron emission tomography (PET)/computed tomography (CT) 
done with no evidence of lytic lesions. You also say that Velcade is medically necessary to ensure the enrollee 
received medical management. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Velcade. Our reviewer says that the 
request for Velcade is not medically necessary. Our physician reviewer found the requested use of Velcade is 
not FDA-approved for the enrollees diagnosis. The reviewer found that the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the 
reviewer found that the requested drug 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 Velcade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Velcade (J9041).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) test (0037U) provided November 29, 
2022. 
 
You asked the Plan to pay for the FoundationOne CDx test. You say that the provision of F1CDx to the 
enrollee meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary 
for the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says that the 
requested test is not reasonable and necessary because your records do not show that the enrollee has advanced, 
metastatic, recurrent, and refractory cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the FoundationOne CDx test. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has presumed advanced non-small cell adenocarcinoma of the lung. Per 
the NCCN Guidelines the integration, NGS testing into the routine management of advanced NSCLC 
demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery 
of molecularly guided therapy. NGS testing such as with FoundationOne is considered a standard of care. The 
service is reasonable and 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 FoundationOne CDx test have been met. Therefore, we decided that the 
Plan has to pay for the FoundationOne CDx (F1CDx) test (0037U) provided November 29, 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: 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 are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
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 appear to be stable enough for transfer and requires 
additional acute care services that can be safely provided at the current facility until more stable and 
appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary and completion 
of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 18, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-
par providers are not covered under an HMO plan unless preauthorized. 
 
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 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 psychotherapy provided on November 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet the 
requirements for non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance services. Our reviewer says 
that the ambulance transport was not medically necessary. Our physician reviewer found the transportation via 
ambulance from the hospital to  home upon discharge was not medically necessary. The enrollee was not 
bedbound, as evidenced by the ability to sit in a chair.  The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Oxygen is routinely used/administered by laypersons via portable oxygen 
tank/concentrator. Transportation could have been provided by other means (stretcher van, wheelchair van, 
private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on June 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 You asked the Plan to pre-approve Durolane. You say that the enrollee has tried Synvisc One. You say that 
Orthovisc is not available in the office. You also say that this medication is necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, Orthovisc. 
 
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 Durolane. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found that you have not tried and failed the 
preferred drug, Orthovisc. The reviewer found that there is no documentation provided indicating that the 
plans required drug would likely be less effective and/or likely have adverse effects for you. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve complete mandibular denture. You say that you cannot eat without dentures. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2019. 
Therefore, we decided that the Plan does not have to pre-approve complete mandibular denture (D5120).
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 services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in another setting such as a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve the services. You say that the lymphedema has remained refractory despite 
adherence to conservative treatments and basic device use. The Plan denied your request. The Plan says that the 
records do not indicate a trial of non-segmented E0651. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is noted to have venous insufficiency and lymphedema affecting the lower extremities. 
The documentation indicates that the enrollee has tried conservative measures, including compression 
garments. Measurements of the enrollees lower extremities indicate that the enrollees edema has not 
improved. The enrollee had a trial with a basic pump, which was noted to be ineffective and did not cover the 
total location of the enrollees edema. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a pneumatic compression device (E0652).  
 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 testing (81352) provided on November 16, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says fasfsafd 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has established the limited coverage 
for acute myeloid leukemia (81352) (AML, and including acute promyelocytic leukemia) molecular 
biomarkers.  
 
We looked at the file and Medicare rules. Per LCA A52986, the billed diagnosis code D46.9 is not covered for 
code 81352. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing (81352) provided on 
November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve inpatient psychiatric hospitalization. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospitalization. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there was no 
indication in the available medical records that the enrollees psychiatric symptoms could not be managed on a 
less restrictive basis. She was noted to be at her baseline mental status and was not exhibiting any other 
significant symptoms such as psychosis or mania. The enrollee did not have any suicidal ideation and 
continued inpatient hospital stay was not required to improve the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 distance 
training is repetitive exercise and does not require input from a skilled therapist. The enrollee is able to transfer, 
walk, toilet bathe and shower independently. 
 
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 three home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. There is no corroboration of progression of the vertebral height loss on the imaging studies. Additionally, the MRI noted 60% central vertebral body height loss at the L1 vertebral body and 3-4mm 
retropulsion of the posterior superior aspect of the vertebral body. Retropulsion is a relative contraindication 
for this procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 percutaneous vertebral augmentation (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting reconsideration for the 
denial of Ubrelvy based on medical necessity and continuation of therapy. 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 Ubrelvy. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 27, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet the 
requirements for non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance services. Our reviewer says 
that the ambulance transport service was not medically necessary. Our physician reviewer found the 
transportation via ambulance from the hospital to the enrollee's residence upon discharge was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on November 27, 2022.
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 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 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is no 
support in the documentation that the enrollee requires the intensive medical care and the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. The medical records do not 
clarify that treatment at the skilled nursing facility level is not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.