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

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. 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 follows Medicare rules. Medicare rules say that Monoclonal Antibodies Directed Against Amyloid 
for the Treatment of Alzheimer's Disease (AD) is covered when certain criteria 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 Leqembi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found given that the drug is not being provided as 
part of an approved clinical study, the use of the medication would not be eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 6, 2023, billed with 
procedure code 73560-26-RT. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the procedure was billed with an invalid diagnosis.  
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality.  
When an anatomic modifier is appended to a line, the laterality of the reported diagnosis must be appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. Procedure code 73560-26-RT was billed with 
diagnosis code Z96.659, which is not appropriate for lines with modifier RT (right) appended. Therefore, we 
decided that the Plan does not have to pay for imaging services provided on April 6, 2023, billed with 
procedure code 73560-26-RT.
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 enrollee currently meets admission criteria. 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 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. 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 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 an electric scooter (K0800). 
 
  You asked the Plan to pre-approve an electric scooter. You say that you had a nuclear test ejection fracture 
21%, and the echocardiogram shows 20 to 25% which proves it is hard for you to breathe. You also say that 
you have neuropathy, fibromyalgia on entire body, Chronic Obstructive Pulmonary Disease (COPD), and you 
have had two major heart attacks and two strokes. The Plan denied your request. The Plan says the clinical 
documentation does not establish medical necessity for an electric scooter. 
 
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.  
 
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 electric scooter. Our reviewer says 
that you do not meet the criteria for coverage. Our physician reviewer found the scooter was requested to assist 
with community ambulation. Our reviewer also found that you do not require the device to complete MRADLs 
in the home. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric scooter (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stelara.  Benefits for Stelara 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Tacrolimus. 
 
You asked the Plan to pre-approve Tacrolimus. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan follows Medicare rules. Medicare rules state that immunosuppressive drugs may be covered by 
Medicare Part B post-transplant under certain conditions. 
 
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 Tacrolimus. Our reviewer says that the 
enrollee does not meet criteria for use of Tacrolimus. Our physician reviewer found the record indicates that 
the enrollee underwent liver transplant in 2014. Therefore, this is excluded from Part B coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tacrolimus have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Tacrolimus.  
 
Benefits for Tacrolimus 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0973, E2310, E0955, E1002, E1028, E2363, and 
E2607). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee cannot pressure relief outside of his base of support and he is a high fall risk out of his 
chair. You also say that a fall out of the chair could be catastrophic. The Plan denied your request. The Plan 
says the enrollee does not have a qualifying diagnosis causing mobility limitation for which K0856 group 3 
power wheelchair is medically needed. Armrests (code E0973) are unbundled from the requested power tilt. 
The Plan also says the electronic connection (code E2310) is not medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is 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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the documentation does not indicate the member has a neurological 
condition, myopathy or congenital skeletal deformity that would qualify for a group 3 PWC. Our reviewer 
found that although the enrollees condition may meet criteria for a PWC, the criteria for this specifically 
requested PWC with multiple power options including power tilt and recline are not 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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0973, E2310, 
E0955, E1002, E1028, E2363, and E2607).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nuclear medicine study of the lymphatic system (78195) 
 
You asked the Plan to pre-approve nuclear medicine study of the lymphatic system. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve nuclear medicine study of the lymphatic 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient literature to support the safety and 
efficacy, as defined by Medicare rules, of the requested service for the enrollee's specific clinical condition. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nuclear medicine study of the lymphatic system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve nuclear medicine study of the lymphatic system (78195)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not being used for an FDA approved or compendia 
supported reason.  
 
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 Truxima. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found there do exist very few non-
randomized trials without a control group that show, to no statistical significance, that perhaps 1 in 3 patients may have a slowing of their progression. Unfortunately, since we do not know the nature of this condition, the 
cause, and that all patients progress differently, it is impossible to tell if the Truxima had any effect. Because 
there is no consensus treatment for this condition and no evidence that the requested therapy is of benefit, the 
denial is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on December 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided on December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acetabular/proximal arthroplasty femoral replacement 
with autograft. 
 
You asked the Plan to pre-approve hip surgery. You say that your quality of life has suffered due to your pain. 
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 hip surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding any significant attempts at weight loss. There 
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. No compelling rationale is presented or extenuating circumstance noted to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hip surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acetabular/proximal arthroplasty femoral replacement with autograft.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
  You asked the Plan to pre-approve SNF care. You say that the enrollee has a fear of going home and they are 
not sure if they are able to perform activities of daily living. You say that the enrollee can benefit from therapy 
five times a week before they can safely return home. The Plan denied your request. The Plan says a SNF 
admission 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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oral sleep apnea device (E0486) purchased 
December 1, 2022. 
 
You asked the Plan to reimburse you for the oral device. You say that you were expecting to be reimbursed for 
the full cost of $2,500.00 for the service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly as this service is not covered. 
 
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 $0 copay 
for Medicare covered DME for Durable medical equipment (DME) and related supplies.  
 
You have been asked for full reimbursement for the oral device. This item/service falls within the Durable medical equipment (DME) and related supplies benefit category. The Plan contract says that the Plan will cover 
all medically necessary durable medical equipment covered by Original Medicare. The oral sleep apnea device 
is not a covered item however, the records show that the Plan did reimburse the Medicare allowable of 
$375.00. The records show that this payment was a one-time exception and will not be recouped by 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 reimburse you for the oral sleep apnea device (E0486) purchased 
December 1, 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 the services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee does not meet the 
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 the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met 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 a ramp. 
 
You asked the Plan to pre-approve a ramp. You say that it is medically necessary for the enrollee to have a 
ramp so that she can get in and out of her house safely, given her acquired mobility issues from chemotherapy. 
The Plan denied your request. The Plan says the ramp is not considered durable medical equipment and is non-
covered.   
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also 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 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. In addition, 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 
pre-approve a ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior interbody lumbar fusion (PLIF). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis 
without neurogenic claudication. Back pain has recurred after spinal fusion in 2005. The exam reveals 
sternocleidomastoid strength is graded at five out of five. Motor exam and sensory exam are intact. The deep 
tendon reflexes are absent in the biceps, triceps, brachioradialis, knees, and ankles bilaterally. He has a notably 
stooped forward posture. There is no detailed documentation of a trial and failure of recent, reasonable, comprehensive and less-invasive conservative care measures. There is no documentation of potential 
impending/inevitable temporary intra-operative instability. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. PLIF is not reasonable or 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve posterior interbody lumbar fusion (PLIF).