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

We decided that the Plan does not have to pre-approve Taltz 80mg/mL autoinjector.

You asked the Plan to pre-approve the Taltz injector. You say that this is necessary. The Plan denied your request. The Plan says this drug is for self-injection and is not covered by 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 Taltz 80mg/mL autoinjector. 

Benefits for the Taltz injector 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 Synvisc-One (J7325). 
 
You asked the Plan to pre-approve the Synvisc-One. The Plan denied your request. The Plan says the 
documentation does not support that Synvisc-One meets the Plan's medical necessity guidelines for coverage. 
 
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 Synvisc-One. Our reviewer says 
that Synvisc-One does not meet coverage criteria. Our physician reviewer found there is no documentation of 
trial and failure or contraindication to first line medicines, such as Orthovisc or Monovisc. 
 
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 Synvisc-One have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc-One (J7325).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that your doctor recommended you be 
admitted to a SNF. You also say that you need more care than what can be given at home. The Plan denied 
your request. The Plan says the records do not show that you require daily skilled nursing or skilled therapy in 
a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF 
admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve the backup. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a 
backup battery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that this is necessary to treat the enrollee's 
metatarsalgia. The Plan denied your request. The Plan says this item is not a covered benefit for the enrollee's 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Otezla. 
 
You asked the Plan to pre-approve the Otezla. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition by Medicare Part B or 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 Otezla.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair (E1399). 
 
You asked the Plan to pre-approve a seat lift chair. You say that you need this because your pain impairs your 
ability to stand and sit. The Plan denied your request. The Plan says you do not meet the criteria for coverage of 
this item. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if you are be 
completely unable to stand up from a regular armchair or any chair in the home. 
 
We looked at this physician's review, the file, and Medicare rules. The record does not show that you are 
completely unable to stand up from all of the chairs in your home. Based on this information, we decided that 
Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift chair (E1399).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Nivolumab injections (J9299). 
 
You asked the Plan to pre-approve the Nivolumab injections. You say that Nivolumab injections are medically 
necessary to treat your cancer. The Plan denied your request. The Plan says that your recent computed 
tomography (CT) scan showed changes. The Plan also says that the information provided did not show a plan 
to restage your disease or change your treatment. 
 
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 the Nivolumab injections. Our reviewer 
says that Nivolumab injections are medically reasonable and necessary. Our physician reviewer found 
Nivolumab is Food and Drug Administration (FDA) approved for the treatment of metastatic non-small cell 
lung cancer that has progressed on or after platinum-based chemotherapy. Patients with estimated glomerular 
filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations should have disease 
progression (on approved EGFR- or ALK-directed therapy) prior to receiving Nivolumab. Our reviewer found 
that you have no driver mutations, and received prior carboplatin based therapy. Our physician reviewer also 
found that the documentation does support that the requested drug is safe and effective, and otherwise 
reasonable and necessary for you. 
 
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 Nivolumab injections have been met. Therefore, we decided that the Plan 
has to pre-approve Nivolumab injections (J9299).  
 
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 pay for the skilled nursing services provided from February 3, 2020 
to March 3, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of 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 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 February 3, 2020 to March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) orbit without contrast 
(70480). 
 
You asked the Plan to pre-approve CT orbit without contrast. You say that the records provided should support 
the necessity of the service in dispute. The Plan denied your request. The Plan says a CT is not supported 
because it would not show the doctor all of the details needed in order to treat you. A detailed picture study 
(magnetic resonance angiography or MRA) of the blood vessels in your brain without contrast dye is more 
likely to show your doctor all of the details they need to see in order to treat you. This study will be approved if 
requested. 
 
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 CT orbit without contrast. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case Our 
physician reviewer found the appeal notes that temporal arteritis is no longer considered in the differential.  
Rather retro orbital tumor is a possible diagnosis.  Based upon the history orbital evaluation is indicated.  CT of 
the orbits would be one of two procedures of choice; the other is orbital MRI.  However, either scan would 
require contrast administration in order to evaluate the orbits and retroconal area for tumor.  The records are 
brief and it cannot be determined if there is any contraindication to contrast such as allergy history, renal 
disease etc.  There is no mention of pacemaker or metallic implant to contraindicate MRI. Thus, further orbital 
imaging is warranted but not the requested CT without contrast. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT orbit without contrast have not been met. Therefore, we decided that the 
Plan does not have to pre-approve computed tomography (CT) orbit without contrast (70480).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) rendered by the out of 
network (OON) provider on February 10, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #22. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the documentation 
does not show that there is pathologic destruction of four or more surfaces, and at least 50% of the incisal edge 
with incisal angle tooth loss. 
 
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 crown 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the 
crown is not medically necessary. Our physician reviewer found the documentation provided does not support 
the need for a crown restoration for tooth #22. Our reviewer also found that there does not appear to be 
significant coronal breakdown due to caries or fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #22.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Selective Internal Radiation Therapy (SIRT). 
 
You asked the Plan to pre-approve Selective Internal Radiation Therapy (SIRT). You say that it is your opinion 
that the Selective Internal Radiation Therapy (SIRT)  is the best palliative treatment option to control disease 
progression in the liver. The Plan denied your request. The Plan says this therapy is considered experimental or 
investigational, due to insufficient evidence to support conclusions regarding the effect of SIRT on health 
outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Selective Internal Radiation Therapy (SIRT) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Selective Internal Radiation Therapy (SIRT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 25mcg Amitiza capsules. 
 
You asked the Plan to pre-approve the Amitiza. You say that you would like reconsideration because this drug 
is therapeutic and the member has been stable while on this medication. The Plan denied your request. The 
Plan says this drug is not covered for the member's condition under Medicare Part B or 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 25mcg Amitiza capsules.  
 
Benefits for the Amitiza 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 there is no reason to 
think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition 
differently compared with therapy provided at a less intensive level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 Keytruda and pemetrexed. 
 
You asked the Plan to pre-approve Keytruda and pemetrexed. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical benefit of these drugs is not shown. 
 
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 Keytruda and pemetrexed. Our 
reviewer says that this drug regimen is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation shows that this is not a standard regimen. The recent computed 
tomography scan shows progression of the enrollee's disease. These drugs are not FDA approved in 
combination after prior use. 

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 and pemetrexed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Keytruda and pemetrexed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient detoxification services rendered from January 
28, 2020 to February 1, 2020. 
 
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 inpatient detoxification services are covered 
when reasonable and 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on January 28, 2020 with acute intoxication with alcohol and severe alcohol use disorder. It was not expected 
that he would improve in a reasonable period of time as he did not have dangerousness to self or others, 
auditory or visual hallucinations, delusions and was not showing any behavioral issues or symptoms of acute 
withdrawal. The records do not support that the inpatient services were 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 inpatient detoxification services rendered from January 28, 2020 to February 1, 2020.