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

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve the Botox. You say that the Botox is being prescribed for migraines. The 
Plan denied your request. The Plan says Botox is not medically necessary at this time. The Plan also says that 
the enrollee does not meet prior authorization criteria rules for Botox. 
 
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 the Botox. Our reviewer says that 
Botox is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no 
documentation that supports that the Botox is medically reasonable and necessary for the enrollee. Our 
reviewer found that there is no documentation that supports that the Botox is safe and effective for the enrollee. 
None of the Medicare-approved compendia support the use of Botox injections for occipital neuralgia. Our 
physician reviewer also found that it is not clear from the provided records that the enrollee clearly has 
migraines. 
 
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 Botox have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Botox (J0585).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 the enrollee would benefit from this 
admission. The Plan denied your request. The Plan says that based on current needs, the plan suggests the 
enrollee remain in the current acute care setting. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee meets the requirements of the LTACH, and would benefit from it. It is reasonable 
to think the enrollee would stay over 25 days. The acute care hospital setting is not necessary at this point. The 
services are medically necessary and indicated. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve admission to a long term acute care hospital (LTACH) 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional psychiatric inpatient care. 
 
You asked the Plan to pre-approve the additional care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical information provided did not support this level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 additional care. Our reviewer says 
that the requested additional care is not medically reasonable or necessary. Our physician reviewer found you 
can be treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory 
or visual hallucinations, delusions and were not showing any behaviors or aggression while not showing any 
acute threats to safety. It did not appear that the services for the dates in question were reasonably expected or 
medically necessary to improve your condition or for the purpose of diagnosis. The health plans denial of 
continued inpatient psychiatric services appears appropriate. 
 
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 additional care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional psychiatric inpatient care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
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 there is no clear benefit of inpatient skilled nursing as opposed to an 
alternative setting for care. 
 
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 the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Keytruda. 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 metastatic clear cell renal cancer. The documentation shows that Keytruda is 
approved for first line. The enrollee is second line and has received prior immunotherapy. Therefore, the 
requested use of Keytruda is not FDA-approved for the enrollee diagnosis. The requested use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered by the Plan. 
 
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 Repatha 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Evenity 105mg/1.17ml syringe 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 that the conditions needed to approve this drug have not been met. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found Evenity 105mg/1.17ml 
syringe is requested to treat severe osteoporosis in this 66 year old woman, with a bone mineral density T-score 
of -3.8 in the left femoral neck, previous history of tibial and lumbar stress fractures, and per the medical 
record, continued loss of bone mass despite treatment with Prolia and Reclast. The prescriber has indicated in 
the the medical record (June 16, 2020) that the plan denied Forteo; therefore Eventiy was ordered at that time. 
The documentation supports that the requested drug is safe and effective for the enrollee's condition, and  
medically 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Evenity 105mg/1.17ml syringe 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: 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 rehab will be beneficial for you. The Plan 
denied your request. The Plan says that your primary condition of advanced dementia is unlikely to allow 
effective, sustained participation and progress in rehabilitation. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer iron sucrose injections (J1756). 
 
You asked the Plan to pre-approve Venofer iron sucrose injections. You say that the enrollee has restless leg 
syndrome and this service is medically necessary. The Plan denied your request. The Plan says this is not 
covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers iron sucrose injection as a first 
line treatment of iron deficiency anemia when furnished intravenously to patients undergoing chronic 
hemodialysis who are receiving supplemental erythropoeitin therapy.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee has iron deficiency anemia 
and is undergoing chronic hemodialysis with supplemental erythropoeitin therapy. Based on this information, 
we decided that Medicare rules for coverage of Venofer iron sucrose injections have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Venofer iron sucrose injections (J1756).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of mitral 
regurgitation with NYSHA Class III congestive heart failure with reduced left ventricular ejection fraction, 
requiring hospitalization. In this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. The efficacy of CardioMEMs is uncertain and the device is considered experimental/investigational in 
nature. The services are therefore 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 pre-approve a CardioMEMs HF System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 to the enrollee by an out-of-network provider 
on May 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for orthopedic surgery (25609, C1713, 80048, 
36415) provided on April 27, 2020 to April 28, 2020. 
 
You asked the Plan to lower the copayment for orthopedic surgery. You say that these services were provided 
in an ambulatory surgical center. The Plan denied your request. The Plan says these services were billed as 
outpatient hospital services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery services provided in an outpatient hospital.  
 
You have been asked to pay a $250 copayment for orthopedic surgery. The record shows that these services 
were billed as being provided in an outpatient hospital rather than an ambulatory surgical center. 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 lower the copayment for orthopedic surgery (25609, C1713, 80048, 36415) provided on April 
27, 2020 to April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for postage/delivery of the durable medical equipment provided 
on April 18, 2020. 
 
You asked the Plan to pay for postage/delivery of the durable medical equipment. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the postage/delivery of the orthosis is not payable. Specifically, postage and delivery fees are non-
covered by Medicare. Based on this information, we decided that Medicare rules for coverage of 
postage/delivery of the durable medical equipment have not been met. Therefore, we decided that the Plan does 
not have to pay for postage/delivery of the durable medical equipment provided on April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) and a psychiatric evaluation (90792) 
provided from March 28, 2019 to March 29, 2019. 
 
You asked the Plan to pay for hospital care and a psychiatric evaluation. You say that this claim was mailed on 
or about February 13, 2020. The Plan denied your request. The Plan says there is no supporting proof that the 
claim was submitted before the Plan received it on April 16, 2020. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital care and a psychiatric evaluation was not filed until April 16, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for hospital care (99232) and a psychiatric evaluation 
(90792) provided from March 28, 2019 to March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a TENS unit (E0730) 
provided to the enrollee on February 18, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that the claim should be paid. The Plan 
denied your request. The Plan says the documentation does not indicate services are necessary for treatment of 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a TENS unit (E0730) provided to the enrollee on February 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to process the claims at the in-network benefit level for the 
psychotherapy services provided from January 8, 2020 to June 22, 2020 by an out-of-network provider. 
 
You asked the Plan to process the claims at the in-network benefit level for the psychotherapy services. You 
say that you were advised the services would be covered. The Plan denied your request. The Plan says based on 
Medicare billing criteria, the claims were billed correctly. 
 
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 40% for 
each Medicare-covered individual and group visit for outpatient mental health care out-of-network.  
 
You have been asked to pay $62.08 for the psychotherapy services. 31.04 (40% of the allowed amount $77.59) 
+ 31.04 = $62.08. 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 process the claims at the in-network benefit level for the 
psychotherapy services provided from January 8, 2020 to June 22, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician service. You say that you have seen this doctor in the past and you 
have never received a bill before. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that this provider is out-of-network with the member's current plan. 
 
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 physician services provided on June 15, 2020 by 
an out of network (OON) provider.