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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you do not drive, and 
you do not have family or friends who can take you to your appointments. The Plan denied your request. The 
Plan says additional trips would exceed your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
twenty-nine (29) one-way transportation trips out of the allowed thirty (30) one-way trips approved. Once 30 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and require IRF services to 
regain your prior level of functioning. The Plan denied your request. The Plan says the request 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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Perjeta infusions to be used in combination with 
Trazimera with Anastrozole. 
 
You asked the Plan to pre-approve Perjeta infusions. You say that the enrollee was diagnosed with Stage IV 
carcinoma of the breast, estrogen and progesterone receptor positive. You also say that the enrollee has 
declined chemotherapy treatment, and you have chosen to treat them with Perjeta and Trazimera. The Plan 
denied your request. The Plan says the criteria for medical necessity have not been met and authorization of 
coverage for Perjeta cannot be provided. 
 
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 Perjeta infusions. Our reviewer says 
that Perjeta infusions are not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Stage IV carcinoma of the breast, estrogen and 
progesterone receptor positive. The FDA has not stated that the requested drug, as prescribed, is indicated for 
the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain 
a supportive citation for the use of the requested drug, as prescribed, in the enrollee's clinical situation. Our 
physician reviewer also found that no literature from Medicare approved cancer journals were submitted for 
review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Perjeta infusions to be used in combination with Trazimera with Anastrozole.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional trips. 
 
You asked the Plan to pre-approve 10 additional trips. You say that you are currently seeking eye treatments 
and are required to be seen several times. The Plan denied your request. The Plan says you do not have benefits 
for additional transportation. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will have, or have, exhausted the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve 10 additional trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, and 87653, billed for date of 
service October 24, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, and 87653. The Plan denied your request. The 
Plan says payment for codes 87150, 87481, and 87653, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481 and 87653 are column 
II codes to column I code 87150. 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 codes 87150, 87481, and 87653, billed for date of service October 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you need rides to your dialysis appointments. 
The Plan denied your request. The Plan says this service is covered under your benefit package, but exceeds the 
maximum count allowed per period. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious agent detection by nucleic acid (87624) provided on 
November 15, 2022. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid. You say that this service was 
medically necessary and was reported correctly. The Plan denied your request. The Plan says that this is not a 
covered code according to Local Coverage Article (LCA) A58710. 
 
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 article referenced by the Plan in this case states only that this 
code is not covered when it is billed in conjunction with other specific codes. The Plan has provided no 
evidence to support that any services, specifically at least one code from groups 1-7 of the mentioned LCA or 
two or more from group 8, were also billed for this enrollee on the same date of service. The only other code 
billed on this claim was code 88175, which is not included in any group or category of the referenced article, 
and no other claims were submitted as evidence to support the Plan's denial. There is no evidence that the code 
at issue was billed with any other service which would render the code non-covered; therefore, the Plan's denial 
is not substantiated in this case. Therefore, we decided that the Plan has to pay for infectious agent detection by 
nucleic acid (87624) provided on November 15, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right breast implant exchange with scar revision. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is undergoing removal of a 
breast lesion. The records do not document a medical rationale for the requested services. The records do not 
support that the requested implant exchange with scar revision is reasonable and medically necessary for the 
enrollee at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right breast implant exchange with scar revision.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trazimera infusions to be used in combination with 
Perjeta and Anastrozole. 
 
You asked the Plan to pre-approve Trazimera infusions. You say that the enrollee was diagnosed with Stage IV 
carcinoma of the breast, estrogen and progesterone receptor positive. You also say that the enrollee has 
declined chemotherapy treatment, and you have chosen to treat them with Perjeta and Trazimera because of 
this. The Plan denied your request. The Plan says the criteria for medical necessity have not been met and 
authorization of coverage for Trazimera cannot be provided. 
 
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 Trazimera infusions. Our reviewer says 
that Trazimera infusions are not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Stage IV carcinoma of the breast, estrogen and 
progesterone receptor positive. The FDA has not stated that the requested drug, as prescribed, is indicated for 
the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain 
a supportive citation for the use of the requested drug, as prescribed, in the enrollee's clinical situation. Our 
physician reviewer also found that no literature from Medicare approved cancer journals were submitted for 
review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trazimera infusions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Trazimera infusions to be used in combination with Perjeta and Anastrozole.
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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF 
have 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. 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: 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 are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (49000-22-53) provided on September 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 49000-
22-53 is not supported by the records provided. Our reviewer found that procedure code 49000 is included in 
the enterotomies surgery, and the provider stated he aborted shorty after entering the enterotomy. This code 
would not be acceptable to be billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (49000-22-53) provided on September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
for the denial of an IRF admission. You say you have two broken ribs and need assistance walking. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary in this case. Our physician reviewer found that there is no 
documentation that the treatment with Keytruda in combination with Trodelvy for advanced, refractory triple 
negative breast cancer meets all Medicare criteria for medically reasonable and necessary for this enrollee. The 
National Comprehensive Cancer Network and the Medicare-approved major drug compendia do not support 
the requested drug regimen in this clinical scenario. there is no documentation that the treatment with Keytruda 
in combination with Trodelvy meets all Medicare criteria for safe and effective for the patient. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the request 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 enrollees 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 IRF admission and services.