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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the  home ventilator. You say that the enrollee is under your care for the 
management of muscle weakness as a result of a left occipital lobe stroke which has led to chronic ventilatory 
impairment and respiratory failure. You also say that the enrollee has shown increased dyspnea and oxygen 
requirements and need of non-invasive ventilatory support in the home.  The Plan denied your request.  The Plan says a home ventilator is not medically necessary for the enrollee because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the  home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee has a history of 
COPD, severe obesity, a bioprosthetic heart valve, and congestive heart failure. While in the hospital the 
enrollee had an episode of acute hypercarbic respiratory failure and evidence for pulmonary edema, that 
improved with diuresis. However, mild hypercarbia persisted in the hospital. This may be related to obesity 
hypoventilation syndrome. There are no pulmonary function tests to confirm airways obstruction or assess its 
severity. There is no diagnosis of neuromuscular disease or thoracic restrictive disease. The enrollee may 
benefit from BiPAP with volume assurance as an outpatient. The records do not show this has been tried. The 
severity of illness does not support the need for a  home ventilator. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya injection. 
 You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria for coverage of this drug have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the 
Plan's step criteria have not been met in this case. Our physician reviewer found that the Plan requires a trial 
of two or more of the following drugs: adalimumab, Skyrizi, Cosentyx, Otezla and/or Enbrel, before they will 
approve the requested drug. In this case, the enrollee has not tried and failed at least two of the required 
drug(s). There is no documentation provided indicating that the plans required drug(s) would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya injection.
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 cannot be managed at a 
lower level of care and risks further deterioration if not approved for LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for LTACH services. 
 
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 patient appears to be somewhat unstable and requires additional acute care 
hospital services that can safely be provided at the current facility until more stable and appropriate for transfer 
to a lower level of care soon. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer and as it would not be clinically advantageous. 
 
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 a Cala Trio Device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala Trio Device. You say that the enrollee is becoming increasingly in 
need of treatment for her tremor. This device has the potential at assisting her with getting back to some 
normalcy as she is burdened with her tremor in all aspects of her life. The Plan denied your request. The Plan 
says the Cala Trio Device is unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala Trio Device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has Parkinson/s Disease. She had an anaphylaxis reaction to Levodopa. 
This is considered an experimental/ investigational device. Therefore, the request is deemed not medical 
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 a Cala Trio Device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio Device (K1018, K1019).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve angiography and peripheral artery revascularization of the leg 
(37231, 37230, 37229, 37228, 37226, 37225 and 37224).  
 
You asked the Plan to pre-approve angiography and peripheral artery revascularization of the leg. You say that 
the clinical information provided supports the need for the services in dispute. You say that further delay in 
approval could jeopardize the enrollees health. The Plan denied your request. The Plan says that your request 
is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that treatment of atherosclerotic obstructive lesions in the 
lower extremities is a covered indication for PTA 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 angiography and peripheral artery 
revascularization of the leg. Our reviewer says that the service is medically necessary. Our physician reviewer 
found the documentation meets coverage criteria and supports the medical necessity of the procedures in 
question. The enrollee has documentation of lifestyle limiting symptoms consistent with the severe lower 
extremity arterial occlusive lesions identified on recent angiography. Specifically, there is documentation of 
80-90% stenosis of the right common iliac artery and 80-90% stenosis of the left common iliac artery. These 
lesions can cause significantly disabling symptoms, and the treatments tend to be durable and are expected to 
significantly improve the enrollees quality of life. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angiography and peripheral artery revascularization of the leg have been met. 
Therefore, we decided that the Plan has to pre-approve angiography and peripheral artery revascularization of 
the leg (37231, 37230, 37229, 37228, 37226, 37225 and 37224).   
 
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: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the inpatient hospital care. We decided that the Plan 
does not have to waive the copayment for the inpatient hospital care.  
 
You asked the Plan to waive the copayment for inpatient hospital care provided by an in-network provider from 
August 2, 2022, to August 3, 2022. You say that you are dissatisfied with the copayment. The Plan says that 
this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the inpatient hospital care.  
 
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 says that you pay a $250 copayment 
per day, days 1-4, for in-network inpatient hospital care, and that cost sharing is not charged on the day of 
discharge. The Plan says you must pay a $500 copayment for the inpatient hospital care. Based on the Plan 
contract, however, you cannot be asked to pay any cost sharing on the day you are discharged. Therefore, we 
decided that the Plan has to reduce the copayment for the inpatient hospital care.  
 
We also decided that the Plan does not have to waive the copayment for the inpatient hospital care. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day, days 1-4, for in-network inpatient hospital care. 
 
These items/services fall within the inpatient hospital care benefit category. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the inpatient hospital care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy. 
 
You asked the Plan to pre-approve the drugs. You say that you are recommending this combination because of 
its proven efficacy and due to a lack of alternative options. The Plan denied your request. The Plan says the 
requested use of this drug combination is not supported. 
 
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 drugs. Our reviewer says that the 
request services are not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
metastatic squamous cell carcinoma of the lung diagnosed in November 2022. Initial treatment was with Carboplatin, Paclitaxel and Pembrolizumab as no driver mutations. The enrollee progressed most recently on 
Taxotere followed by Gemcitabine. For further progression, treatment with Opdivo and Yervoy is 
requested. These drugs are only indicated as first-line therapy. Their use is not supported by one of the major 
drug compendia, or by a Medicare-approved clinical journal. They are not safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo and Yervoy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee tolerated bilevel positive 
airway pressure (BIPAP) and average volume-assured pressure support (AVAPS) can be delivered via 
BIPAP. There is no indication provided per documentation to support failure of BIPAP or BIPAP with 
AVAPS. Hence, there is no indication for a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transluminal angioplasty (PTA). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not 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 the surgical services. Our physician 
reviewer found the enrollee has leg pains but is able to continue walking. While the enrollee has a history of 
peripheral vascular disease, the non-invasive studies provided are not consistent with severe disease. In 
summary, there is insufficient documentation to support the medical necessity for lower extremity angiography 
and revascularization of bilateral iliac arteries in this enrollee's clinical management. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous transluminal angioplasty (PTA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee was prescribed a ventilator after a 
life-threatening COPD exacerbation. The device is medically necessary. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee was admitted and appropriately 
treated for COPD exacerbation and tolerated BIPAP therapy. The enrollee did not require escalation of therapy 
and improved with provided BIPAP. Whether BIPAP, with or without average volume-assured pressure 
support (AVAPS) is provided, should be appropriate for the treatment of her chronic respiratory failure. Hence, 
there is no indication home ventilator at this junction, given data and documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane and pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Abraxane and pembrolizumab (Keytruda). You say that the requested drugs 
are medically necessary to treat the enrollee's cancer diagnosis. The Plan denied your request. The Plan says the 
intended use for the requested 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 Abraxane and pembrolizumab 
(Keytruda). Our reviewer says that the requested drugs do not meet the criteria required for approval. Our 
physician reviewer found the enrollee has recently progressed on prior immunotherapy with pembrolizumab. 
The requested use is not supported by one of the major drug compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Abraxane and pembrolizumab (Keytruda) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Abraxane and pembrolizumab (Keytruda).
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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer 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 that the enrollee appears to still be somewhat unstable and requires additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
The patient does not require services at the LTACH that are not already available at the current facility.  Transfer to the LTACH is not medically necessary as the patient is not yet stable for transfer and as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tysabri. 
 
You asked the Plan to pre-approve Tysabri. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the drug requested is not included in Part B 
coverage when dispensed from a pharmacy directly to the enrollee. 
 
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 Tysabri.  
 
Benefits for Tysabri may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.