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

 
We decided that the Plan does not have to pay for lab services (0241U) provided on January 14, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0241U) provided on 
January 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of stage IV malignant neoplasm (adenocarcinoma) of upper lobe 
right lung. Treatment with Opdivo 240 mg/24 mL intravenous solution (J9299) (in a regimen of Opdivo + 
Yervoy + Carboplatin) is not Food and Drug Administration-approved for the diagnosis of stage IV malignant 
neoplasm (adenocarcinoma) of upper lobe right lung with disease progression after treatment with immune 
checkpoint inhibitor plus chemotherapy. Therefore, the enrollee does not meet criteria for the requested drug. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Ti-Trikes T-150 recumbent tricycle (E1399). 
 
You asked the Plan to pre-approve a recumbent tricycle. You say that you need this equipment to return to 
bicycling as you used to prior to your accident. The Plan denied your request. The Plan says this item is not 
covered because it is considered exercise equipment. 
 
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 Ti-Trikes T-150 recumbent tricycle (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra (J0517). 
 
You asked the Plan to pre-approve Fasenra. The Plan denied your request. The Plan says the usage is not 
reasonable and necessary because the enrollee does not have severe asthma. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Fasenra. Our reviewer says that Fasenra 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found Fasenra (J0517) is 
FDA-approved for the treatment of severe asthma in patients with an eosinophilic phenotype. The enrollee in 
this case has a diagnosis of severe chronic obstructive pulmonary disease with high eosinophilia and 
unspecified asthma, uncomplicated. Our reviewer found that the records indicate the enrollee's provider has 
stated that the enrollee does not have a diagnosis of severe asthma. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
(CMS) approved medical journal. Our reviewer found that the use is not indicated, supported or recommended 
in any of the compendia for the enrollees diagnosis. Our physician reviewer also found that the use of Fasenra 
for the enrollees diagnosis does not meet Medicare criteria for safe and effective and otherwise reasonable and 
necessary for this 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 Fasenra have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Fasenra (J0517).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient office visit (99205) percutaneous 
implantation of neurostimulator electrode array, epidural (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that based on the denial letter, you are 
unclear on how to prove medical necessity, so you are making this appeal with this letter. The Plan denied your 
request. The Plan says the enrollee did not meet the criteria of permanent spinal cord stimulator implant 
procedure for chronic back pain.  
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the enrollee had psychological clearance in Dec 2022.  A repeat is not necessary. The enrollee is being treated by a neurosurgeon and even though it seems obvious that the physician would recommend an 
operation if one were indicated, it is not explicitly stated in the notes that the enrollee is not a surgical 
candidate. The enrollee meets all of the other criteria for a spinal cord stimulator.  At this point in time, 
however, 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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve outpatient office visit (99205) percutaneous implantation of neurostimulator electrode 
array, epidural (63650).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Libtayo. 
 
You asked the Plan to pre-approve Libtayo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug 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 Libtayo. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of gastric-type mucinous adenocarcinoma of cervix with a history 
of disease progression on Keytruda. The requested use of Libtayo is not Food and Drug Administration-approved for the treatment of adenocarcinoma of cervix. The use of Libtayo for the treatment of gastric-type 
mucinous adenocarcinoma of cervix with a history of disease progression on Keytruda is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The cited 
New England Journal of Medicine article submitted with this request did not include patients with a history of 
disease progression on immune checkpoint inhibitor therapy. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Libtayo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on October 5, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the benefit limit was 
exceeded. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that one annual 
wellness visit is covered each year. 
 
Review of the file shows that the enrollee was provided an annual wellness visit on October 5, 2022. The records also show that another annual wellness visit was processed and paid by the Plan on the same date of 
service. As this was the second annual wellness visit provided in the same year, the benefit limit has been 
exceeded, and the requested visit is not covered. Therefore, we decided that the Plan does not have to pay for 
the annual wellness visit provided on October 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the enrollee has tried steroid injections, weight loss, 
physical therapy, knee brace, shoe insoles, and home exercise. You also say that injections will help with the 
quality of the enrollee's life. The Plan denied your request. The Plan says this request is denied under the 
Medicare Part B benefit because the records show this drug will be supplied by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage.  Therefore, we decided that 
the Plan does not have to pre-approve Orthovisc (J7324).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a radical nephrectomy procedure (50545) to be provided at an out-
of-network (OON) facility. 
 
You asked the Plan to pre-approve a radical nephrectomy. You say that you have seen the provider previously 
and want to continue. The Plan denied your request. The Plan says that rules for coverage for OON services 
have not been met. 
 
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 does not have contract providers 
located within reasonable distance and travel time from your home who can provide a radical nephrectomy. 
Under Medicare rules, this means that contract providers are not accessible to you.  Therefore, we decided that 
the Plan has to pre-approve a radical nephrectomy procedure (50545) to be provided at an out-of-network 
(OON) facility.  
 
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 pay for nursing facility care provided on October 11, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 nursing facility care provided on October 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammography provided on December 8, 2022. 
 
You asked the Plan to pay for the screening mammography. You say that your provider has recommended 
annual mammograms and the cost of your previous mammograms have been covered for years. The Plan 
denied your request. The Plan says per the members 2022 benefit plan, the member is allowed to have one 
screening mammogram every 12 months. The member had a mammogram screening on February 9, 2022, and 
a second screening on December 8, 2022.  
 
The Plan contract says that the Plan covers one screening mammogram every 12 months for women age 40 and 
older.  
 
We looked at the file and the Plans rules. The file shows that you received a mammogram screening on 
February 9, 2022, and a second screening on December 8, 2022. The Plan covers one screening mammogram 
every 12 months and you have exceeded the benefit limit. Therefore, we decided that the Plan does not have to 
pay for a screening mammography provided on December 8, 2022.
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 you need rehab following surgery. The Plan denied 
your request. The Plan says the IRF services you are requesting 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports 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. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary.  The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found clinical documentation shows that the enrollee has had functional and clinical status 
change thus would be expected to require ongoing assessment by skilled therapy and skilled nursing. Clinical 
documentation shows that all inpatient therapy goals have been met (SBA with ambulation of > 200ft and with 
self-care tasks). No specific recommendation given for frequency of ongoing skilled nursing assessment 
required thus documentation does not show that the enrollee requires daily skilled services. From a practical 
standpoint, clinical documentation does not show that the enrollee requires daily skilled services on an 
inpatient basis in a skilled nursing facility, thus 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push wheelchair. 
 
You asked the Plan to pre-approve a push wheelchair. You say that the item is necessary. The Plan denied your 
request. The Plan says a second wheelchair is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. A power wheelchair serves the same purpose as a push 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a push wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. You say that the records 
provided support the need for the services in dispute. The Plan denied your request. The Plan says ablation 
procedures are not supported by research to treat pain in the joint that connects the pelvis to the tailbone. 
 
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 radiofrequency ablation of the 
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this is considered experimental therapy because of the 
wide variation in efficacy in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.