Persius/hicric huggingface dataset:
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 will benefit more from an inpatient rehabilitation 
facility with your journey to recovery. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services requested do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were  admitted for 
seizures. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical 
records support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is unproven and not medically necessary, due to insufficient evidence of 
efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Coflex device.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the enrollee has a growing left upper lobe lung 
mass. The Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the enrollee's case is unique in that they have 
undergone whole brain radiotherapy for multiple (19) brain metastases in the setting of metastatic lung cancer 
managed with systemic chemo-immunotherapy. As the brain metastases have been well-controlled the enrollee 
is being considered for definitive therapy for the thoracic disease which has progressed on recent imaging. As 
PET/CT imaging would change management it would be standard of care to consider it at this point. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability 
and failure of such a device has not been documented. The enrollee does not meet criteria for the requested 
device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of fam-trastuzumab deruxtecan-nxki. 
 
You asked the Plan to pre-approve fam-trastuzumab deruxtecan-nxki. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 fam-trastuzumab deruxtecan-nxki. Our 
reviewer says that the enrollee does not meet criteria for this drug. Our physician reviewer found fam-
trastuzumab deruxtecan-nxki is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. 
The requested use is not supported by one of the major drug compendia or by clinical research in one of the Medicare-approved medical journals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fam-trastuzumab deruxtecan-nxki have not been met. Therefore, we decided 
that the Plan does not have to pre-approve use of fam-trastuzumab deruxtecan-nxki.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 16, 
2023. 
 
You asked the Plan to pay for procedure code 99291. You say that the medical records should be reviewed for 
payment. The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for 
code 92950. 
 
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 99291 
is a column II code to column I code 92950. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 16, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the enrollee is in a 
lot of pain and would benefit from this device. The Plan denied your request. The Plan says medical studies 
have not proven this service/item is helpful for the treatment of the enrollee's health problem. 
 
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 a Vertiflex Superion Interspinous 
device. 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, and more research is 
needed. 
 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
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 services are medically necessary,  
The Plan denied your request. The Plan says the records do not show that the enrollee has ongoing treatments 
that must be performed in a hospital or that they require a long hospital stay that averages 25 days. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that given the preponderance of 
evidence to support medical necessity for proton therapy in this enrollee, you request the denial be overturned 
and proton therapy to be approved for the enrollee. The Plan denied your request. The Plan says additional 
information on appeal indicates the enrollee has enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve proton treatment delivery as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve proton treatment delivery (77523).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service September 
19, 2022, to October 18, 2022. You asked the Plan to pay for the billed services. You say that everything was billed correctly. The Plan denied 
your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 19, 2022. The NOA was not received by the Plan until January 
12, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service September 19, 2022, to October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). The home ventilator is being 
requested for use in average volume assured pressure support (AVAPS) mode which is a modality that could be 
provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. Medicare does 
not cover a home ventilator for this use and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System (33289). 
 
You asked the Plan to pre-approve a CardioMEMs HF 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 a CardioMEMs HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary 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 a CardioMEMs HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMs HF System (33289).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's required drugs, alendronate, 
zoledronic acid, or ibandronate. The records do not show that the required drugs would be contraindicated or 
less effective; therefore, Evenity is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA NP percutaneous disc allograft. 
 
You asked the Plan to pre-approve the VIA NP percutaneous disc allograft. You say that the VIA NP 
percutaneous disc allograft is medically necessary. The Plan denied your request. The Plan says based on 
Medicare rules, the request for VIA NP percutaneous disc allograft is not approved. The records show the 
enrollee has chronic back pain with degenerative disc disease. 
 
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 VIA NP percutaneous disc allograft. 
Our reviewer says that the requested VIA NP percutaneous disc allograft is not considered medically 
reasonable and necessary. Our physician reviewer found that the VIA NP percutaneous disc allograft is 
considered experimental/investigational at this time. Therefore, the request is deemed not medically reasonable and 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 VIA NP percutaneous disc allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the VIA NP percutaneous disc allograft.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Anoro Ellipta. 
 
You asked the Plan to pre-approve Anoro Ellipta. You say that Anoro Ellipta is medically necessary. 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 Anoro Ellipta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor (E0667) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance. You say that 
there are no contracted providers in the local area that are trained, skilled or credentialed in performing custom 
calibrations on-site at the enrollees home for an E0652 customized calibration pump. You also say that those 
other contracted providers can only ship to home and/or they cannot do on-site calibrations to expectations of 
the ordering doctor. The Plan denied your request. The Plan says coverage for an OON provider for the 
requested services has been denied. The Plan also says this is available by an in-network provider. 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor (E0652) and segmental pneumatic appliance for use with pneumatic compressor 
(E0667) to be provided by an out-of-network (OON) provider.