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

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says Medicare Part B programs can only provide limited 
benefits for prescription drugs. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that you would like reconsideration because this 
scooter is medically necessary. The Plan denied your request. The Plan says the records show that the member 
will keep this scooter in the car, therefore, it is not to use in the home. 
 
The Plan must follow Medicare rules. The rules 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 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 power scooter (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Otezla 28 day pack. 
 
You asked the Plan to pre-approve Otezla. You say that Otezla is medically necessary. The Plan denied your 
request. The Plan says this type of drug is not eligible for coverage under the Part B medical benefit. 
 
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 an Otezla 28 day pack.  
 
Benefits for Otezla 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 Dexilant. 
 
You asked the Plan to pre-approve Dexilant.. You say that Dexilant is medically necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says Medicare Part B programs can only provide 
limited benefits for prescription drugs. 
 
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 Dexilant.  
 
Benefits for Dexilant. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physical therapy. 
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says the requested provider is not in network. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these services. Therefore, we decided that the Plan does not have to pre-approve out of network 
physical therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bavencio. 
 
You asked the Plan to pre-approve Bavencio. You say that you would like the plan to reconsider their 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 Bavencio. 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 renal cell (kidney) cancer that has been treated with multiple drugs previously. 
The approved and supported use of Bavencio in renal cancer is as first line treatment in combination with 
Axitinib. The requested use is not FDA approved. The requested use is not supported in any of the CMS 
approved compendia. 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 Bavencio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Bavencio.  
 
 
 
 
 
 
 
 
 
 
Benefits for Bavencio 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 the shingles vaccine. 
 
You asked the Plan to pre-approve the shingles vaccine. You say that this is preventative maintenance and it is 
cheaper to get the vaccine instead of getting shingles. The Plan denied your request. The Plan says this 
immunization is not covered by your Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pre-approve the shingles vaccine.  
 
Benefits for the shingles vaccine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to remove excess fat and skin (15830 and 
15834). 
 
You asked the Plan to pre-approve surgery to remove excess fat and skin. You say that this is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is covered 
when medically necessary per the above guidelines. 
 
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 surgery to remove excess fat and skin. 
Our reviewer says that the requested services are not medically necessary. Our physician reviewer found there 
is insufficient documentation that typical upper and lower abdominal panniculectomy is indicated.  
Photographs are not supportive of a significant pannus overhang, as well as medical documentation to support a 
functional impairment to pannus overhang. Thus, the medical documentation does not support that there is a 
significant functional impairment related to a overhanging upper or lower abdominal pannus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery to remove excess fat and skin have not been met. Therefore, we decided 
that the Plan does not have to pre-approve surgery to remove excess fat and skin (15830 and 15834).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on April 10, 2020, to April 20, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says care at this level 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 above 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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee on April 10, 2020, to April 20, 
2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF.  Specifically, the records do not show you require fifteen hours per week of rehabilitative 
services and regular physician evaluation. 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from a course of acute 
inpatient rehab. The Plan denied your request. The Plan says the enrollee does not require three hours of 
therapy per day at least five days per week. The Plan also says that the enrollee is not expected to benefit 
significantly from intensive rehabilitative therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is no documentation that the enrollee requires the intensive 
rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tablets. 
 
You asked the Plan to pre-approve Ondansetron tablets. The Plan denied your request. The Plan says this 
medication does not fall under Part B coverage. 
 
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 Ondansetron tablets.  
 
Benefits for Ondansetron tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants for upper and lower arches (D6010). 
 
You asked the Plan to pre-approve dental implants for upper and lower arches (D6010). You say that the 
requested dental implant with code D6010 is medically necessary. The Plan denied your request. The Plan says 
the requested dental implant with code D6010 does not meet criteria. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers dental 
implants for lower arches (D6010) only when the services are medically necessary and reasonable.  
 
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 dental implants for the lower arch 
(D6010). Our reviewer says that the requested dental implant with code D6010 does not meet criteria. Our 
physician reviewer found the documentation provided appears to be incomplete. Radiographs were not 
submitted and there was no indication as to why an implant was needed. There appeared to be missing 
maxillary and mandibular posterior teeth which could be replaced by removable appliances or fixed 
 
 
bridgework. The documentation provided was not sufficient to determine if the criteria for coverage for an 
implant have been met. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental implant on the 
upper arch is not among those covered under this benefit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental implants for upper and lower arches (D6010) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve dental implants for upper and lower arches 
(D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
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 care can be safely received in another setting, such as a skilled nursing 
facility, or home with home health 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include respiratory support with BIPAP weaning , oxygen 
supplementation, nebulizer treatments, telemetry, surveillance laboratory studies, tube feedings, and therapy 
services. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where he is currently receiving care. There are no required medical 
services identified that are available at the LTACH, that are not available at the current health care setting 
being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are in an acute rehab facility, and it is 
not safe enough for you to go home. The Plan denied your request. The Plan says your request for approval of a 
SNF admission from an inpatient rehabilitation facility does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do 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. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature or 
upgraded electronics. 
 
You asked the Plan to pre-approve the power seat elevation feature and upgraded electronics. You say that the 
enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the 
power seat elevation feature is not covered and the upgraded electronics are not medically needed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item power seat elevation feature 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. The enrollee's 
evaluation shows the enrollee has the strength to control the power options using their own switches. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation 
feature or upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Group 2 power wheelchair upgraded electronics. 
 
You asked the Plan to provide power wheelchair upgraded electronics. You say that the enrollee will greatly 
benefit from a custom power chair to complete MRADLs. The Plan denied your request. The Plan says 
although there are three approved power options on this wheelchair there is not a medical need to control these 
power options through the joystick, as the power options come with their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if 
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is 
medically necessary.  
 
The file shows that the enrollee is physically able to control the power features through their own individual 
switches. Therefore, we decided that the Plan does not have to provide Group 2 power wheelchair upgraded 
electronics.