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

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested care is needed at 
the SNF level and should be reconsidered. The Plan denied your request. The Plan says the enrollee has used 
their 100 days of SNF care and the benefit is currently exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 5 through 
September 12, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says home health 
services are available within your 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 requested 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 home 
health services 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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you are receiving the appropriate care in the Inpatient Rehabilitation 
Facility. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you would like the enrollee to continue 
treatment with the provider. The Plan denied your request. The Plan says there are providers available within 
the enrollee's 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 requested 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 
cardiology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652) 
and sleeves (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says that criteria for coverage are not met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 
Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device 
(E0652) and sleeves (E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar or sacral, single level (CPT Code 64483) and 
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including 
arthrography when performed (CPT Code 27096). 
 
You asked the Plan to pre-approve the services. You say that the back pain interferes with your activities of 
daily living. 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you do not have an indication for sedation during a sacroiliac (SI) joint injection. You are not 
morbidly obese, have obstructive sleep apnea (OSA), unstable medical condition or psychiatric illness. The 
diagnosis of SI joint is not confirmed by the usual physical exam maneuvers and therefore, the request is 
deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar or sacral, single level (CPT Code 64483) and Injection procedure for sacroiliac 
joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed 
(CPT Code 27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic services out of area. 
 
You asked the Plan to pre-approve the out of area orthopedic services. You say that you are out of state 
temporarily, but need to see an orthopedic provider as soon as possible. You say that your right knee is swollen 
and painful. You say that you are having trouble walking. The Plan denied your request. The Plan says there is 
no clinical information to support the need for care out of area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The case file shows that the Plan made reasonable attempts to obtain 
some sort of clinical information from you, from your established in area primary care provider, and from the 
requested orthopedic provider. Despite these attempts, there was no clinical documentation or medical records 
provided to support that the Medicare criteria for coverage of out of area care have been met. The information 
provided did not demonstrate that the need for this care was unforeseen or that the care being requested could 
not be reasonably delayed until you return to the service area. Based on this information, we decided that 
Medicare rules for coverage of the out of area orthopedic services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve orthopedic services out of area.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Lurbinectedin (Zepzelca). 
 
You asked the Plan to pre-approve Zepzelca. You say that Lurbinectedin was recently food and drug 
administration (FDA) approved as treatment of small cell carcinoma, that have had disease progression after 
the completion of the platinum based treatment. The Plan denied your request. The Plan says that the use of 
Zepzelca does not meet the criteria for coverage. 
 
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 Zepzelca. Our reviewer says that 
Zepzelca is medically reasonable and necessary for the enrollee. Our physician reviewer found the requested 
use of Zepzelca is FDA-approved for the enrollee's diagnosis. Small cell cancers of other areas are treated just 
as you would small cell carcinoma of the lung. Our reviewer also found that the use is not listed as not 
indicated, not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zepzelca have been met. Therefore, we decided that the Plan has to pre-approve 
Lurbinectedin (Zepzelca).  
 
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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that Lucentis is medically necessary. The Plan denied 
your request. The Plan says a trial of Avastin, Mvasi or Zirabev is required. 
 
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 Lucentis. Our reviewer says that 
coverage criteria is not met. Our physician reviewer found based on the medical records provided there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
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 Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyproheptad. 
 
You asked the Plan to pre-approve Cyproheptad. 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 a covered 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 Cyproheptad.  
 
Benefits for Cyproheptad 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 Ketorolac Tromethamine 10 mg tablets for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Ketorolac Tromethamine 10 
mg tablets for the enrollee.  
 
Benefits for this drug 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: 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. The Plan denied your request. The Plan says the enrollee does not 
require intensive, complex interdisciplinary 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 physician reviewer found 
that you suffered a left-sided stroke, and now have right hemiparesis. You most recently sustained a fall, and 
right femoral neck fracture. You are now medically stable and non-toxic. The complexity of your nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. You are at minimal assist for basic activities of daily living and mobility. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses purchased on April 6, 2020. 
 
You asked the Plan to reimburse you for the eyeglasses purchased from an out-of-network provider. You say 
that your physician recommended this provider. The Plan denied your request. The Plan says they confirmed 
you did not have a referral and this provider is not part of the network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services for 1 pair of standard lenses and frames every 2 years provided by a 
specific provider. 
 
We looked at the file and the Plan's rules. You did not purchase the eyeglasses from the Plan specific provider. 
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.  
Therefore, we decided that the Plan does not have to reimburse you for eyeglasses purchased on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
17, 2019. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have never paid for 
laboratory services in the past and disagree with the charges. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $10 
copayment for laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with 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 waive the copayment for laboratory services provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on August 19, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when 
specific 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of residual 
melanoma in situ in a biopsy scar site on the mid-back. The documentation does not support that there is 
significant uncertainty about the adequacy of microstaging or that there are other adverse features, 
lumphovascular invasion, or that the enrollee has a T1b or T2 tumor. The services were not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-Melanoma testing rendered on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 6, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under your plan unless they are authorized by the 
Plan before the services are provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on December 6, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on June 25, 2019. 
 
You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
colonoscopy. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a colonoscopy provided on June 25, 2019.