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

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is FDA approved for the enrollee's 
condition regardless of origin. The Plan denied your request. The Plan says the LCD criteria for the enrollee's 
area have not been met, and this request is not approved at this time. 
 
The Plan follows Medicare rules. Medicare rules say that per the LCD, chemotherapy agents may be covered if 
the criteria listed in the Medicare rules section of this letter are met. 
 
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 for the enrollee. Our physician reviewer found FDA 
approval for Keytruda in the setting of metastatic gastric cancer mismatch repair (MMR) deficient by IHC is a 
second- or third-line therapy after progression. If using it as first line therapy, guidelines suggest Keytruda in 
addition to chemotherapy. Our reviewer also found that there are no guidelines, and the FDA does not approve 
of monotherapy use with Keytruda as first line therapy. 
 
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 (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this should not require authorization. The Plan 
denied your request. The Plan says out-of-network services require authorization. 
 
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 items/services 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay to the pneumatic compression device (E0675) provided on 
December 9, 2022, through December 30, 2022. 
 
You asked the Plan to pay to the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay to the pneumatic compression device (E0675) provided on December 9, 2022, through December 30, 2022.
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 it is medically necessary. The Plan 
denied your request. The Plan says it is not medically necessary. 
 
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 in current acute care setting as provided by 
Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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 a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power mobility device. You say that you are requesting reconsideration of 
the denied PMD. The Plan denied your request. The Plan says the notes indicate that at present, the enrollee is 
walking with a walker, and does not indicate that his needs could not be met with a manual wheelchair. The 
enrollee has not had a home evaluation to ensure his home has enough room to accommodate the power 
scooter. The enrollee does not meet criteria for a PMD. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  The file shows that the enrollee does not have a mobility deficit that impairs his participation in MRADLs, that 
his condition can be improved by a walker, cane or manual wheelchair or that he can safely operate the PMD 
being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient weight 
capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medial branch block. 
 You asked the Plan to pre-approve the medial branch block. You say that the enrollee had a recent failure of 
physical therapy for lower back pain. The Plan denied your request. The Plan says the medial branch block is 
not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medial branch block. Our reviewer 
says that the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee trialed 
physical therapy three years ago with no relief and has not had six weeks of conservative care in the past year. 
Also, the MRI shows another cause of the enrollee's back pain that is not related to the facet joints for which 
the enrollee received improvement from an epidural steroid injection. The criteria requires that there can be no 
other cause of back pain on imaging studies, therefore the enrollee does not meet the LCD coverage criteria. 
 
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 medial branch block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the medial branch block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the service requested is not supported based on the 
records received.  
 
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 The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy 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 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 11, 2022, billed 
with evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The enrollee was in outpatient observation on 
this date of service, as such the reported POS 21 is inappropriate. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on October 11, 2022, billed with evaluation and management 
(EM) code 99233.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from an 
admission to an LTACH to regain a maximum/prior level of functioning and to continue a multidisciplinary 
approach to care. You also say the LTACH setting is necessary to perform the appropriate care and 
management of the enrollee's complex needs. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates the enrollee has ongoing acute medical issues and still requires acute care services. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway 
collapsibility (E0485). 
 
You asked the Plan to pre-approve an oral device/appliance. You say that the oral device will help the enrollee 
sleep. The enrollee has a condition that causes her to stop breathing when asleep. The Plan denied your request. 
The Plan says the request is not medically necessary because the records show you are asking for a device that 
Medicare says is not effective therapy for sleep apnea. 
 
The Plan must follow Medicare rules. Medicare rules say that a prefabricated oral appliance will be denied as 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oral device/appliance have not been met. Specifically, the LCD states that there is insufficient 
evidence to show that the requested oral device is effective therapy for OSA, therefore, it is denied as not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve an oral 
device/appliance used to reduce upper airway collapsibility (E0485).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Doxil (Q2050). 
 
You asked the Plan to pre-approve Doxil. You say that the enrollee had an allergic reaction to first line 
treatment paclitaxel and the requested Doxil is a substitute. The Plan denied your request. The Plan says that 
the use of this drug/regimen is not reasonable and 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 Doxil. Our reviewer says that Doxil is 
medically reasonable and necessary for the enrollee. Our physician reviewer found Doxil is similar to 
paclitaxel. They are one of standard chemotherapies used for the enrollee's cancer type, and share major parts 
of their structures and mechanisms of action. Doxil is frequently used and studied to be safe. Our reviewer also 
found that given that the enrollee had a reaction to paclitaxel, they are at risk for a reaction with Doxil, but does 
not make this unsafe to be given. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Doxil have been met. Therefore, we decided that the Plan has to pre-approve 
Doxil (Q2050).  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says you 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. 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 inpatient rehabilitation facility. 
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status.  You can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breathing circuits (A4618), the home ventilator (E0466) 
and the humidifier (E0550). 
 You asked the Plan to pre-approve the durable medical equipment (DME). You say that the ventilator is 
medically necessary. The Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee was on no medical therapy and is an active smoker, all of 
which could have led to the enrollee's acute chronic obstructive pulmonary disease (COPD) exacerbation.  
Initiation of bilevel positive airway pressure (BiPAP) or ventilatory support, prior to initiation of medical 
therapy and compliance, is not indicated. The enrollee's documentation does not support the need for 
ventilatory support at this time. Furthermore, since the ventilator is not covered, the other DME is not covered. 
 
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 breathing circuits (A4618), the home ventilator (E0466) and 
the humidifier (E0550).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy at an out-of-network (OON) facility.  
 
You asked the Plan to pre-approve a colonoscopy at the OON facility. You say that you do not have 
transportation to the network facility, which is 40 minutes from you. You say that it would be easier to find 
transportation to the closer OON facility. You say that its necessary for you to have a colonoscopy as soon as 
possible.  The Plan denied your request. The Plan says there are network providers available who can provide a 
colonoscopy.  
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide a colonoscopy. Under Medicare 
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy at an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the esophagoscopy provided on February 14, 2023, 
and the specialist office visits, and x-ray provided on April 24, 2023. 
 
You asked the Plan to waive the cost share for the esophagoscopy, office visits, and x-ray. You say that you do 
not see where the items are listed that you need to pay for. The Plan denied your request. The Plan says that 
this cost sharing was applied correctly. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC) for the dates 
of service being appealed. Without the correct EOC we are unable to determine if the cost share was applied 
correctly. Therefore, we decided that the Plan has to waive the cost share for the esophagoscopy provided on 
February 14, 2023, and the specialist office visits, and x-ray provided on April 24, 2023.  
 
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.