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

 
We decided that the Plan does not have to pre-approve Avastin 25 mg/ml intravenous solution. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider has not demonstrated why an exception would be medically necessary. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found you have not trialed 
Mvasi and Zirabev.  Step therapy, as outlined by the plan, requires these be trialed first. The documentation 
does not outline contraindications or reason this medication was not considered. Without the support of the 
documentation, Avastin intravenous solution not approved as step criteria is 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Avastin 25 mg/ml intravenous solution.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel for the 
enrollee. 
 
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested code cannot be approved for this type of panel. 
 
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 panel. Our reviewer says that the 
requested panel is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a diagnosis of myelodysplatic syndrome. The requested study looks for genes involved 
in cancer. The request is for a panel of genes, but the specific genes requested are not outlined. Without this 
documentation, the request cannot be considered for medical necessity related to this enrollee's medical 
diagnoses. 
 
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 panel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve targeted genomic sequence analysis panel for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transfer Tubular Slide Sheet. 
 
You asked the Plan to pre-approve a Transfer Tubular Slide Sheet. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a Transfer Tubular Slide Sheet is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a Transfer Tubular Slide Sheet.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs will not be met at a lower level 
of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in 
other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted after a fall with head 
trauma. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for tooth #'s 13 & 14. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says this service is 
allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to once per 60 
months per tooth. The record shows that you received crowns on tooth #'s 13 & 14 on August 28, 2019, and 
your crowns benefit for tooth #'s 13 & 14 has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve crowns for tooth #'s 13 & 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you were given an estimate for 
dentures, and then it was denied. The Plan denied your request. The Plan says this service is only covered 1 
time in a 60 month period. The Plan also says that you have already had this service done in that time period. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to 1 complete or 
partial denture every 5 years. The record shows that you received a maxillary partial denture on January 30, 
2019 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a complete maxillary denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sleep Number bed. 
 
You asked the Plan to pre-approve a Sleep Number bed. You say that you need this because you cannot sleep 
and are having constant pain. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a Sleep Number bed.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of chest, abdomen and pelvis 
with contract coded as 71260 and 74177. 
 
You asked the Plan to pre-approve the CT scan. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says that the clinical information does not support 
that this service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that this 
service is considered medically necessary in this case. Our physician reviewer found while chest x-ray is 
generally the first imaging test of choice in the workup of unintentional weight loss the fact is in this case even 
a negative chest x-ray would not obviate the need for further workup.  The concerning facts in this case are not 
just the weight loss (not quantified in the records!) but also the elevated white blood cell count and especially 
the elevated CEA which is a tumor marker.  While the clinical findings could reflect a flare up of rheumatoid 
arthritis elimination of other potential causes such as occult neoplasm especially lymphoma is necessary and 
CT of the chest, abdomen and pelvis would be the most appropriate choice. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) scan of chest, abdomen and pelvis with contract coded as 71260 and 
74177.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency medical transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency medical transportation trips. The Plan denied 
your request. The Plan says you have used 36 of the 36 allowed trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency medical transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the enrollee does not have qualifying conditions. 
 
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 the enrollee 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 preapprove a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV). 
 
You asked the Plan to pre-approve a POV. You say that you get dizzy and your knees give out causing you to 
fall. The Plan denied your request. The Plan says that you walk in your home without an assistive device. 
 
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 patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair or that you cannot safely operate the 
POV being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power operated vehicle (POV).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
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. You 
are medically stable with no post-op complications. There is no documented evidence of medical issues that 
require monitoring by an inpatient rehab physician three times a week. The documentation does not support 
that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to 
rehab care at the current functional status. Your rehab needs can be met in an alternate, less intense setting. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: 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 this is not medically necessary. 
 
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 hemodialysis, surveillance laboratory studies, surgical 
wound care, decubitus skin wounds, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0005) and 
accessories (K0108, E0961, E2611, E2201, E1020, E0973, E2601, E2203, E0951, E0971, K0040). 
 
You asked the Plan to pre-approve a lightweight manual wheelchair and accessories. You say that the enrollee 
needs this because he cannot use his prosthesis full time. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchair are covered when medically 
necessary per the criteria listed 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 a lightweight manual wheelchair and 
accessories. Our reviewer says that the requested items are not medically necessary. Our physician reviewer 
found the records show that it is anticipated that the enrollee will only need the wheelchair temporarily until his 
stump is healed and he is able to walk, thus not meeting Medicare criteria for full-time manual wheelchair 
usage and medical necessity. 
 
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 lightweight manual wheelchair and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0005) and 
accessories (K0108, E0961, E2611, E2201, E1020, E0973, E2601, E2203, E0951, E0971, K0040).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services, spinal surgery, and hospital 
discharge pharmacy charges provided from March 25, 2019 through April 5, 2019. 
 
You asked the Plan to pay for these services. You say that you would like this to be paid by the Plan. The Plan 
denied your request. The Plan says that this was not an emergent situation and is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded. 
 
We looked at the file and Medicare rules. These services were not furnished in the United States. 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 inpatient hospital services, spinal surgery, and hospital 
discharge pharmacy charges provided from March 25, 2019 through April 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant services, abutments, and guided tissue 
regeneration. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services 
are not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental 
implant services, abutments, and guided tissue regeneration.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from November 12, 
2019, to December 31, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the enrollee should have been covered 
for up to the 100 days because it was a medically necessary situation. The Plan denied your request. The Plan 
says the services were no longer reasonable and 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from November 12, 2019, to December 31, 
2019.