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

We decided that the Plan has to pre-approve additional Eylea (Aflibercept injections code J0178).
You asked the Plan to pre-approve Eylea. You say that the enrollee needs this medication in both eyes for his
diabetic macular edema. You also say that the enrollee has tried Avastin. The Plan denied your request. The
Plan says that the recommended dosing for the requested medication is 1 dose every 4 weeks for 5 doses, then
every 8 weeks. The Plan also says that this is 6 doses per eye for the requested authorization period.
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 Eylea. Our reviewer says that Eylea
meets the Plan's coverage criteria. Our physician reviewer found the enrollee has tried and failed Avastin
(Bevacizumab) in 2019.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve
additional Eylea (Aflibercept injections code J0178).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has a history of hypercapnic
respiratory failure. The Plan denied your request. The Plan says the enrollee has not tried and failed a BiPAP
device.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator. Our physician
reviewer found that the enrollee has COPD and small cell lung cancer, with recent hospitalizations for acute
respiratory failure. There is no documented failure of BiPAP treatment. Medicare does not cover a home
ventilator when used as BiPAP. Therefore, a home ventilator is not 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 a home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after June 26,
2020.
You asked the Plan to pre-approve SNF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before June 26, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services after June 26, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve home health visits. The Plan denied your request. The Plan says the enrollee
does not have a medical problem that needs special care that only a skilled person can do.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health visits. Our physician
reviewer found that the enrollee does not have documented skilled nursing needs. There is no evidence of a
recent hospitalization or changes in medication. There is no documentation of a need for IVs or wound care.
Therefore, the requested services are not medically reasonable and 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 home health visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature.
You asked the Plan to pre-approve the requested feature. The Plan denied your request. The Plan says a seat
elevator does not serve a primarily medical purpose.
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. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation feature.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and treatment to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit and treatment to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K0800 power mobility device (PMD).
You asked the Plan to pre-approve a PMD. You say that a PMD is medically necessary. The Plan denied your
request. The Plan says the Medicare coverage criteria for a PMD are not met.
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.
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 PMD. Our reviewer says that
Medicare coverage criteria for a PMD are not met. Our physician reviewer found the medical record
documentation does not indicate that you require a PMD inside the home to complete activities of daily living.
The documentation states you are unable to use a cane or manual wheelchair due to weakness, but the medical
records themselves do not include a detailed neuromuscular exam of the upper extremities indicating any
muscle motor strength deficits. Therefore, the medical records provided do not support the statements made
regarding upper extremity capability. Since there is no medical record documentation to show you are unable to
use a cane, walker, walker with wheels or manual wheelchair in the home, the Medicare coverage criteria for a
PMD are 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 a PMD have not been met. Therefore, we decided that the Plan
does not have to pre-approve a K0800 power mobility device (PMD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.
You asked the Plan to pre-approve Praluent. You say that the enrollee had to discontinue her statin therapy due
to elevated liver function test. You also say that the enrollee can no longer take the statins due to the risk of
elevated liver function. The Plan denied your request. The Plan says this drug is not covered for the enrollee's
condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Praluent.
Benefits for Praluent 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.
You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want the enrollee treated with this
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to Monovisc and Orthovisc.
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 Synvisc-One (J7325). Our reviewer
says that criteria is not met for this drug. Our physician reviewer found the enrollee reportedly has
osteoarthritis of the knee. A request has been made for Synvisc-One, a hyaluronic acid injection, to treat the
osteoarthritis. The health plan requires that other forms of hyaluronic acid injections be used first. There is no
evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no
evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There
is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and
effective for the enrollee. Therefore, the requested Synvisc-One is not shown to be currently medically
necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One (J7325) have not been met. Therefore, we decided that the Plan
does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (77525).
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The
Plan denied your request. The Plan says the records do not show why proton beam radiation therapy is the best
choice.
The Plan follows Medicare rules. Medicare rules say that for all indications that are not listed above, proton
beam radiation therapy is not considered reasonable and necessary and will be denied.
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 proton beam radiation therapy. Our
reviewer says that the criteria for coverage of proton beam radiation therapy have not been met. Our physician
reviewer found there is no compelling data to suggest that proton therapy is superior to or more beneficial than
other treatments. The generally accepted standard of care for prostate cancer is to only offer proton beam
therapy on clinical trials, and to not routinely offer it to patients. The records do not show that the enrollee has
a condition listed as covered in the LCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve proton beam radiation therapy (77525).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Brain
(70551).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
MRI is not medically necessary. Our physician reviewer found there is no specific clinical rationale for the
requested MRI of the brain. The record did not document a history or mental status exam to support a diagnosis
of mild cognitive impairment. Per the guidelines on mild cognitive impairment, a combination of cognitive
testing and information from a person who has frequent contact with the enrollee, such as a spouse or other
care provider, is the best way to more fully assess cognitive impairment
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the Brain (70551).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that it is important for the enrollee's
safety if transportation could continue. The Plan denied your request. The Plan says the enrollee's benefit only
allows 60 trips for this service.
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 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Once the enrollee has received 60 oneway
trips, the Plan's maximum benefit for coverage of routine transportation will be exhausted. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation.
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 you are appealing with records. The Plan denied
your request. The Plan says the denial of authorization for IRF service is correct.
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. The enrollee is
mostly moderate/minimal assist overall for functional transfers and activities of daily living. A less intensive,
longer duration of therapy would allow for measurable gains to be attained within a predicted period.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the information
submitted doesn't meet 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 Durolane. Our reviewer says that
Durolane does not meet coverage criteria. Our physician reviewer found the case file does not contain
documentation of trial and failure of Orthovisc and Monovisc. Our reviewer also found that the documentation
does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse
effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (Durvalumab).
You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says the requested drug is
used in patients with unresectable stage III disease.
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 Imfinzi. Our reviewer says that Imfinzi
(Durvalumab) Our physician reviewer found that the enrollee has stage IIIA non-small cell lung cancer. The
enrollee was resected and received prior immunotherapy with Nivolumab. A computed tomography provided
on June 11, 2020, shows no progression. The requested use of Imfinzi is not FDA-approved for the enrollee's
diagnosis. Approved treatment is for unresectable stage III non-small cell lung cancer in adults whose disease
has not progressed following concurrent platinum-based chemotherapy and radiation therapy. Therefore, the
requested drug is not considered medically reasonable and 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to
pre-approve Imfinzi (Durvalumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation and therapeutic drugs for a dental extraction.
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your
request. The Plan says the services are not covered.
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 sedation and
therapeutic drugs for a dental extraction.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of current spinal cord stimulator with a
high frequency device and all associated procedures.
You asked the Plan to pre-approve replacement of current spinal cord stimulator with a high frequency device
and all associated procedures. You say that you would like the plan to reconsider their denial. The Plan denied
your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that replacement of current spinal cord stimulator is only
covered for certain indications.
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 replacement of current spinal cord
stimulator with a high frequency device and all associated procedures. Our reviewer says that the
documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the documentation does not show that the standard stimulator cannot be repaired. There is no clinical need for high frequency over standard stimulator. The records do not support the
need for high frequency stimulator. Therefore, the enrollee does not meet criteria for the requested 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 replacement of current spinal cord stimulator with a high frequency device and
all associated procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve
replacement of current spinal cord stimulator with a high frequency device and all associated procedures.