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

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says that the enrollee's condition does not meet the 
criteria for coverage. 
 
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 
criteria for coverage have been met. Our physician reviewer found Keytruda is FDA-approved for the treatment 
of adult patients with unresectable or metastatic tumor mutational burden-high (TMB-H) [greater than or equal 
to 10 mutations/megabase (mut/Mb)] solid tumors, as determined by an FDA-approved test, that have 
progressed following prior treatment and who have no satisfactory alternative treatment options. The use of 
Keytruda is not listed as not indicated, not supported or not recommended in any of the compendia. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for the enrollee. Keytruda has been demonstrated to be safe and effective in patients with lung cancer. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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 the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the LTACH 
admission.  
 
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 is receiving appropriate care at the present acute care facility. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on September 18, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on September 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show a medical need 
for the requested power options. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options 
and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertiflex interspinous spacers. 
 
You asked the Plan to pre-approve vertiflex interspinous spacers. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for approval. 
 
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 vertiflex interspinous spacers. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertiflex interspinous spacers have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertiflex interspinous spacers.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Delvance. 
 You asked the Plan to pre-approve Delvance. You say that the requested drug is necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says the requested drug does not meet the step therapy 
requirements for approval. 
 
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 Delvance. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the Plan 
requires a trial of other susceptible antibiotics before they will approve the requested drug. Based on the 
medical records provided there is no indication that the enrollee has tried and failed the other possible 
intravenous drugs, such as cefazolin, oxacillin, linezolid or vancomycin among others. Based on the medical 
records and the Medicare-approved major drug compendia, there is no indication that the Plan's required drugs 
would likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Delvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Delvance.
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 appealing the denial of the 
LTACH services. The Plan denied your request. The Plan says the LTACH is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 was admitted for chronic obstructed pulmonary disease (COPD) 
exacerbation, acute on chronic respiratory failure, and pneumonia. There is no documentation provided 
indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade 
to expandable controller (E2313), electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), and power standing system (E2301). 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and power 
standing system. You say that the services are necessary. The Plan denied your request. The Plan says medical 
necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 an expandable controller, harness, 
electronic connection, and power standing system. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's upper 
extremity strength and functional ability as shown by being able to food preparation support that this enrollee 
can control any power options through their own switches. The E2301 power standing system does not serve a 
primary medical purpose and the physician documentation does not support that this feature will be safe for the 
enrollee to use given his history of spastic paresis and unsteady stance. 
 
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 expandable controller, harness, electronic connection, and power standing 
system have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable 
controller (E2377), harness for upgrade to expandable controller (E2313), electronic connection between 
wheelchair controller and two or more power seating system motors (E2311), and power standing system 
(E2301).
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 is appropriate for IRF care. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage.  
 
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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee can be transferred to 
LTACH level of care for continuation of complex medical needs that require ongoing acute care. The Plan 
denied your request. The Plan says the LTACH services are not medically necessary, and the enrollee's needs 
are being met in the current hospital location. 
 
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 has a history of of oxygen dependent chronic obstructive pulmonary 
disease (COPD), hypertension, and hyperlipidemia who was admitted to an acute care facility with a diagnosis of sepsis, pneumonia, acute on chronic respiratory failure. There is no documentation provided indicating 
medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute 
care facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233-
25) rendered on May 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, documentation of 
additional evaluation and management service as well as a procedure report was not submitted and was unable 
to review for overlapping services. 
 
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 evaluation and management services (procedure code 99233-25) rendered on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathy services provided on September 25, 2023. 
 
You asked the Plan to pay for naturopathy services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services are not covered under any 
circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathy services provided on September 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care provided on June 18, 2022. 
 
You asked the Plan to pay for observation care. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim must be filed no later than the close of the period 
ending 1 calendar year after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for observation care was not filed until August 29, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for observation care provided on June 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on July 29, 2023, to 
August 2, 2023.  
 You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. 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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found the clinical 
documentation does not provide a signed plan of care from enrollees physician for home health care services 
thus the home health services provided from July 31, 2023, to August 2, 2023, were 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on July 29, 2023, to August 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick device and supplies (A6590, A7001, 
A7002). 
 
You asked the Plan to pre-approve a Purewick device and supplies. You say that the requested items are 
medically necessary due to a urinary tract infection. The Plan denied your request. The Plan says the requested 
items are not covered by Medicare as they are considered convenience or 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 pre-approve a Purewick device and supplies (A6590, A7001, A7002).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network chiropractic services. 
 
You asked the Plan to pre-approve the out-of-network chiropractic services. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve out-of-network chiropractic 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on August 16, 2023, to 
September 6, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says you can request reimbursement for the cost of these 
services under your Part D plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on 
August 16, 2023, to September 6, 2023.  
 
Benefits for immunization services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.