Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick system. 
 
You asked the Plan to pre-approve a Purewick system. You say that the requested Purewick system is 
medically necessary.  The Plan denied your request. The Plan says the requested Purewick system 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 a Purewick system. Our reviewer says 
that the requested Purewick system is not medically necessary.  Our physician reviewer found the enrollee does 
not meet the above LCD/LCA criteria for the requested Purewick system. The records do not show that the 
enrollee has permanent urinary incontinence that would require the use of a chronic indwelling catheter which 
is required by the LCD/LCA.  
 
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 Purewick system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Purewick system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection administration provided on 
February 09, 2023. 
 
You asked the Plan to waive the copayment for the injection administration. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for the injection administration. This item/service falls within 
the in-network outpatient surgery, including services provided at ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the injection administration provided on February 09, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 Receiver. 
 
You asked the Plan to pre-approve a Dexcom G7 Receiver. You say that the enrollee is currently using 
Dexcom G6 products, so you do not agree with the denial. The Plan denied your request. The Plan says that the 
Medicare criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G7 Receiver. Our reviewer 
says that Medicare criteria has been met. Our physician reviewer found the provided criteria state that if the 
enrollee is using insulin, then would qualify for CMG coverage. This enrollee is using  insulin and likely 
adjusts their doses based on blood sugar level; a1c is 7.2. Therefore, criteria for CGM coverage are 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 a Dexcom G7 Receiver have been met. Therefore, we decided that the Plan has 
to pre-approve a Dexcom G7 Receiver.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3, per sq cm (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega3. 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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that records show that the enrollee's wounds are pressure ulcers. 
In addition, the records do not show there that there is adequate nutrition to allow wound healing. The review 
has determined that the items/services at issue in this case are 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3, per sq cm (Q4158).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 10, 2022, to 
April 4, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted a RAP first and then found 
out you needed to submit an NOA. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
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 February 8, 2022. The NOA was not received by the Plan until May 12, 
2022. 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 services 
provided from March 10, 2022, to April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cologuard test provided on July 8, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the cologuard test. You say that this test provides information to aid in the 
appropriate treatment plan for the enrollee. The Plan denied your request. The Plan says enrollees must receive 
their care from a 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 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 had network providers 
available who could have provided the item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the cologuard test provided on July 8, 2022, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Gemtesa 75 mg tablet medication (J8499). 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. 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 drug requested here is not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve the Gemtesa 75 mg tablet medication 
(J8499).  
 
Benefits for this 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. 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 an EGD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records show several inconsistencies with the provider's accompanying statement 
and supports that the enrollee is under treated for dyspepsia and gastroesophageal reflux disease (GERD), has a 
longstanding not new onset history of epigastric pain, and that his reflux has been low grade. Clinical 
correlation was not provided to support the provider's assertion that the enrollee has a history of Barrett's 
esophagus. Medical appropriateness criteria warrant a proton-pump inhibitor (PPI) trial and re-evaluation of 
treatment response prior to consideration of another EGD as is under this 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 an EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an esophagogastroduodenoscopy (EGD) (43235).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine thyroid scan (78013). 
 
You asked the Plan to pre-approve a nuclear medicine thyroid scan. 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 a nuclear medicine thyroid scan. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that 78013 is the code for a thyroid scan/uptake. This is used 
when the enrollee has thyrotoxicosis to determine etiology (thyroiditis vs hyperthyroidism). The parathyroid 
scan typically includes a subtraction of the thyroid uptake to help read the parathyroid scan. 
 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 nuclear medicine thyroid scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a nuclear medicine thyroid scan (78013).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV). 
 
You asked the Plan to pre-approve the POV. You say that you are unable to walk due to severe blood clots in 
your legs. The Plan denied your request. The Plan says the requested POV is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Group 2 power operated vehicles (POVs) have 
added capabilities that are not needed for use in the home and therefore is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Group 2 power operated vehicle (POV).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from January 3, 2023, to March 
30, 2023. 
 
You asked the Plan to pay for the medical services. You say that you were not on hospice on the dates of 
service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 You ended Medicare Hospice benefits on March 9, 2023. The services in question were provided before the 
end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided from 
January 3, 2023, to March 30, 2023.
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. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda 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 the 
requested Keytruda is not medically necessary. Our physician reviewer found based on the medical records 
provided and the guidelines of the National Comprehensive Cancer Network and the Medicare-approved major 
drug compendia there is no support that monotherapy with Keytruda for PD-L1 negative metastatic non-small 
cell lung cancer meets all Medicare criteria for medically reasonable and necessary for the enrollee. Based on 
the medical records provided and the guidelines of the National Comprehensive Cancer Network and the 
Medicare-approved major drug compendia there is no support that monotherapy with Keytruda for PD-L1 
negative metastatic non-small cell lung cancer meets all Medicare criteria for safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 2, 2022, to 
November 21, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  
 
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 November 2, 2022. The NOA was not received by the Plan until February 
2, 2022. 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 home health services provided 
from November 2, 2022, to November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 24, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 24, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that the enrollee has been diagnosed with post-menopausal 
osteoporosis and a FRAX score of 33.2%. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred drugs, zoledronic acid or pamidronate. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drugs, zoledronic acid or pamidronate. The reviewer also 
found that there is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
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 ventilator is medically reasonable or necessary. Our physician reviewer found the enrollee is essentially bed ridden and has a PEG tube. The enrollee was 
hospitalized on June 6, 2023, with sepsis and aspiration pneumonia, one day after an unsuccessful attempt to 
change the percutaneous endoscopic gastrostomy (PEG) tube. The enrollee suffered a cardiac and respiratory 
arrest two days after admission and was intubated. After extubation the enrollee was treated intermittently with 
bilevel positive airway pressure (BiPAP). Arterial blood gas on the day of admission was consistent with mild 
acute on chronic hypercarbic respiratory failure. On June 21, five days after extubation, the PaCO2 was 49. 
There is no diagnosis of chronic obstructive pulmonary disease (COPD). Kyphosis is mentioned as a diagnosis 
but is not confirmed on physical examination or chest imaging. There are no pulmonary function tests to assess 
the severity of the restrictive lung disease. There is no arterial blood gas (ABG) test done while stable to 
document chronic CO2 retention. If that is present, the enrollee may benefit from BiPAP during sleep as an 
outpatient. The enrollee does not have a diagnosis for which Medicare covers a home ventilator. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. Therefore, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says the step therapy 
requirements have not been 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 the drug. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed 
the required drug Venofer. Also, there is no documentation indicating that the Plan's required drug would likely 
be less effective or likely have adverse effect 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (99233) provided from August 23, 
2022, through August 24, 2022.  
 
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says the records 
do not support the billed codes for August 23, 2022, and August 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the physician services have been met. 
Specifically, no medical records were submitted for dates of service August 23, 2022 and August 24, 2022. 
Therefore, we decided that the Plan does not have to pay for the physician services (99233) provided from 
August 17, 2022, through August 24, 2022.