Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the proton beam radiation therapy. 
 
You asked the Plan to pre-approve the proton beam radiation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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 proton beam radiation therapy. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no plausible explanation for why more standard of care treatments would not 
be feasible in this patient 
 
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 proton beam radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you have not received a 
power wheelchair within the past five years as the Plan has stated. You also say that you would like this request 
to be reconsidered. The Plan denied your request. The Plan says this request is not a covered benefit because 
your records do not show evidence of irreparable damage to your current power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. 
 
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 group 2 standard power wheelchair. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation available for review does not support that the 
current group 2 power wheelchair is irreparable therefore the replacement power wheelchair is 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 a group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve waterjet ablation of the prostate. You say that the procedure would take care 
of the health issue you are having with emptying your bladder. You say that you currently have to get up to go 
to the bathroom every so often because you are not eliminating properly. The Plan denied your request. The 
Plan says you do not meet the Medicare LCD coverage criteria as you are 81 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that waterjet ablation of the prostate is covered when 
the criteria listed in the Medicare rules section of this decision are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of waterjet ablation of the prostate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve waterjet ablation of the prostate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluorouracil, Pembrolizumab, and Carboplatin. 
 
You asked the Plan to pre-approve the Fluorouracil, Pembrolizumab, and Carboplatin. You say that these drugs 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the Fluorouracil, Pembrolizumab, and 
Carboplatin. Our reviewer says that this drug combination is not medically necessary. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of  p16 positive squamous cell carcinoma of the 
tonsil and has had progression of disease with previous Pembrolizumab therapy. The Food and Drug Administration, Medicare-approved  drug compendia, and medical literature do not support the use of the 
requested drug combination for the enrollee's condition. 
 
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 Fluorouracil, Pembrolizumab, and Carboplatin have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Fluorouracil, Pembrolizumab, and 
Carboplatin.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve the home health services. You say that the enrollee has urinary issues. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health services. Our physician 
reviewer found that the enrollee has a past medical history of multiple medical comorbidities. Clinical 
documentation does not specify any acute clinical status changes, medication or plan of care changes. The 
records do not show that 6 additional home health skilled nursing visits are required to effectively provide 
treatment to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the 
enrollees condition and/or prevent deterioration. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on October 15, 2022, billed 
with codes 87798, 87481 and 87653. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on October 15, 2022, billed with codes 87798, 87481 and 87653.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is required to assist in further 
diagnosis. The Plan denied your request. The Plan says the PET scan is not medically necessary. 
 
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 a PET scan. Our reviewer says that the 
requested PET scan does not meet the criteria necessary for approval. Our physician reviewer found the most 
recent nasal endoscopy and MRI results show no evidence of a mass. The documentation and medical 
reasoning provided was unclear of why a PET scan is needed 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections. 
 
You asked the Plan to pre-approve sacroiliac joint injections. 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 sacroiliac joint injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not have a physical examination to suggest that the sacroiliac joint 
is reasonably considered the pain generator. There is no sacroiliac joint tenderness on examination and there 
have been no provocative maneuvers performed. Further, the treating provider has already performed a 
therapeutic sacroiliac joint injection and documented in the medical records that it was not efficacious. 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 sacroiliac joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 3, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says these services were not billed correctly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen.  The records provided show that the services at 
issue were indeed OIVIT services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OIVIT services have not been met. Therefore, we decided that the Plan does not have to pay 
for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet the medical 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered experimental in 
nature and are not medically necessary for the treatment of chronic knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric treatment from 
September 13-forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric treatment. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of September 13, 2023 forward and could have been 
treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, or delusions. He was not showing any behaviors or aggression. The enrollee was being 
cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric treatment from September 
13-forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (BiPAP) with 
supplies, oxygen concentrator, and Nebulizer, to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a BiPAP with supplies, oxygen concentrator, and Nebulizer. You say that 
the items should be covered. The Plan denied your request. The Plan says there are in-network providers 
available to obtain the items. 
 
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 bilevel positive airway pressure (BiPAP) with supplies, oxygen concentrator, and Nebulizer, to be provided 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot stand without assistance or care 
for themselves. They are a fall risk and require SNF care. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
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 that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 a continuation of SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits (99345, 99344, 99347, 99348, 99349, 
99350, 99497, 99490, 99439, 99487, 99489, 99491, 99453, 99454, 99457, 99458, 99458, 99493, 99494, 
G0438, G0439) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that the services should be covered. The Plan 
denied your request. The Plan says there are in-network providers available to perform these services. 
 
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 
the office visits (99345, 99344, 99347, 99348, 99349, 99350, 99497, 99490, 99439, 99487, 99489, 99491, 
99453, 99454, 99457, 99458, 99458, 99493, 99494, G0438, G0439) to be provided by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin, pembrolizumab and pemetrexed. 
 
You asked the Plan to pre-approve carboplatin, pembrolizumab and pemetrexed. You say that the services are 
medically necessary for the enrollee to be treated as soon as possible. The Plan denied your request. The Plan 
says the documents do not support that the medication requested is proven to treat the enrollee's condition. 
 
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 carboplatin, pembrolizumab and 
pemetrexed. Our reviewer says that the medications requested are not medically necessary. Our physician 
reviewer found the requested use of carboplatin, pembrolizumab and pemetrexed are not FDA approved for the 
enrollees diagnosis. The use of the requested medications is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The use of the medications 
is listed as not indicated, not supported or not recommended in any of the compendia. The request for 
carboplatin, pembrolizumab and pemetrexed cannot be approved 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 carboplatin, pembrolizumab and pemetrexed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve carboplatin, pembrolizumab and pemetrexed.
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 for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the required skilled 
rehabilitation and skilled nursing services can be provided safely and appropriately at a lower level of care such 
as a skilled nursing facility (SNF). 
 
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. 
 
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.