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

 
We decided that the Plan does not have to pre-approve a FreeStyle Freedom Lite Kit w/Device, FreeStyle 
lancets and FreeStyle Lite In Vitro test strips. 
 
You asked the Plan to pre-approve these items. You say that you are currently using these products. The Plan 
denied your request. The Plan says that there is no prescriber rationale that the preferred glucose products 
cannot be used for medical reasons. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiary?s medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of blood glucose meter. Without this, medical necessity 
cannot be established. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Freedom 
Lite Kit w/Device, FreeStyle lancets and FreeStyle Lite In Vitro test strips.
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 you must complete your full course of acute hospital treatment. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his level 
of pain, anxiety and delayed progress with therapy. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Urolift procedure (CPT Codes: 52442 and 52441). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the available documentation, the request does not meet criteria because there is 
no documentation of the enrollee's prostate volume, any other medications tried and failed (notes only indicate 
trial of one (1) medication)  and there is no documentation of absence of obstructive median lobe of the 
prostate. 
 
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 coverage criteria for Urolift procedure (CPT Codes: 52442 and 52441) have not been met. 
Specifically, recent prostate volume has not been assessed, absence of obstructing median lobe has not been 
confirmed, and urodynamics are not consistent with bladder outlet obstruction. 
 
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 the Urolift procedure (CPT Codes: 52442 and 52441).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing skilled nursing facility (SNF) care beyond 
November 29, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee has required daily skilled 
care since admission. The Plan denied your request. The Plan says the enrollee no longer required or received 
daily skilled care beyond 11/29. 
 
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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on 11/18/2020 with low potassium levels. The patient was previously in a SNF for acute kidney 
insufficiency and discharged to long term care on 11/6/20. At prior SNF discharge, he required maximal assist 
of two and was dependent for all care and not able to ambulate.  
 
The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF.  The patient does not have complex wound care or other ongoing SNF level SN need. 
 
The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of 
these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary 
services on 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ongoing skilled nursing facility (SNF) care beyond November 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 2, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and additional intraoral x-rays 
(D0230) provided on August 28, 2020. 
 
You asked the Plan to pay for the bitewing x-rays and additional intraoral x-rays. You say that these services 
were medically necessary. The Plan denied your request. The Plan says you have exhausted your benefit for 
bitewing x-rays and additional intraoral x-rays are not covered when there is no record of payment for the first 
intraoral x-ray. 
 
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 the bitewing 
x-rays and additional intraoral x-rays when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Regarding the bitewing x-rays, you last had 
bitewing x-rays in July 2020 and exhausted your benefit for this service. Regarding the additional intraoral x-
rays, there is no evidence that you are being billed for the first set of intraoral x-rays (D0220). Based on this 
information, we decided that the Plan's rules for coverage of the bitewing x-rays and additional intraoral x-rays 
have not been met. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) 
and additional intraoral x-rays (D0230) provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the dental services. We decided that the Plan does not have to pay for .  
 
You asked the Plan to pay for the dental services. You say that you cannot afford the charges.  
 
We decided that the Plan has to pay for the dental x-rays.  
 
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 file shows that you received intraoral periapical x-rays (D0220 and D0230). We looked at the file and the 
Plan?s rules. The records provided do not show that you received two x-rays in the 2020 calendar year prior to 
the date of service at issue. Based on this information, we decided that the Plan?s rules for coverage have been 
met. Therefore, we decided that the Plan has to pay for the dental x-rays provided on February 25, 2020.  
 
We also decided that the Plan does not have to pay for nutritional counseling, or oral hygiene 
instructions. 
 
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 services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for nutritional counseling, 
or oral hygiene instructions provided on February 25, 2020. 
 
 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found there is no 
documentation provided necessitating admission to a LTACH. The enrollee remains hemodynamically unstable 
for transfer evidenced by the need for the Rapid Response Team involvement. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 Desvenlafax 50mg extended-release tablet for the 
enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is denied as a benefit exclusion. 
 
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 Desvenlafax 50mg 
extended-release tablet for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Ajovy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has migraines. She is under the 
care of a neurologist and has tried and failed multiple medical therapies. She has been using Ajovy for the past 
eight months with positive effect. The Ajovy is reasonable and medically necessary and safe and effective for 
the enrollee based on the submitted records. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Ajovy.  
 
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 Rituximab.

You asked the Plan to pre-approve Rituximab. The Plan denied your request. The Plan says the drug is not supported for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Rituximab. Our physician reviewer found that Rituximab has not been approved by the FDA for use in chronic inflammatory demyelinating polyneuropathy (CIDP). It is not supported in the Medicare accepted Compendia for use in CIDP. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Rather the Compendia are silent on the use of Rituximab in CIDP. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you are at risk for falls. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC 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 pre-approve these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have a personal mobility deficit but it is not clear that it impairs your participation in mobility-related activities 
of daily living (MRADLs) in the home. The documentation is conflicting regarding why your mobility 
limitation cannot be helped by a manual wheelchair. There is no detailed exam of your arms and upper 
extremity strength. It is not clear that you would be able to safely maneuver the PWC in your home. The 
records do not support that the criteria are met; therefore, the PWC is not reasonable or medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast reduction surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the enrollee does not meet criteria for this surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that breast reduction is covered if the above criteria 
have been met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient has well 
documented evidence of significant symptomatic macromastia that has failed conservative management. She 
has back, neck and shoulder pain that has failed conservative analgesia for a greater than 6-month period. She 
also has intertriginous maceration (chronic rashes) that have been refractory to steroidal (dermatologic) 
measures. Her degree of resection is proportional to her body surface area calculated as 2.09. A 650-gram 
resection is consistent with this. Our physician reviewer found that the enrollee's condition meets Medicare 
criteria for coverage for these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve breast reduction surgery for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the treatment is medically necessary as to not 
compromise the enrollee's health. The Plan denied your request. The Plan says the services were not urgent, 
emergent, or approved in advance. 
 
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 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. 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 the medical services provided on August 24, 2020 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology medical exam provided 
on July 25, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology medical exam. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received an ophthalmology medical exam on the date of 
service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the 
Plan. 
 
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 $50 
copayment for Vision care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received an ophthalmology 
medical exam on July 25, 2020. You have been asked to pay a $50 copayment for the ophthalmology medical 
exam. The ophthalmology medical exam falls within the Vision care 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 the ophthalmology medical exam provided on July 25, 2020.