Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Onivyde. 
 
You asked the Plan to pre-approve the Onivyde. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says that the enrollee does not have a medically 
accepted indication for coverage of the requested drug. 
 
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 the Onivyde. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has metastatic pancreas cancer. 
Our physician reviewer found that Onivyde is indicated in combination with 5fu/Leucovorin for metastatic 
pancreas cancer after disease progression and following Gemzar based chemotherapy. The requirements for 
coverage have been met based on the package insert for Onivyde. 
 
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 Onivyde have been met. Therefore, we decided that the Plan has to pre-
approve Onivyde.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the BRCA gene testing with Next Generation Sequencing (NGS). 
 
You asked the Plan to pre-approve the NGS BRCA panel. You say that this expanded panel should be allowed 
to help identify risk. The Plan denied your request. The Plan says that the enrollee has already tested negative 
for BRCA mutations so this is not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing for multiple genes is considered 
necessary when the above 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 the NGS BRCA panel. Our reviewer 
says that the requested testing panel is considered medically necessary in this case. Our physician reviewer 
found an individual's personal and/or family history may be explained by more than one inherited cancer 
syndrome; thus, phenotype-directed testing based on personal and family history through a multi-gene panel 
test may be more efficient and cost-effective and increase the yield of detecting a pathogenic/likely pathogenic 
variant in a gene that will impact medical management for the individual or his/her at-risk family members. A 
retrospective analysis of 337 patients who met NCCN criteria for BRCA1/2 mutation testing and underwent 
multigene testing showed that 25 patients (7.4%) had non-BRCA mutations.  The largest studies reporting on 
the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent 
have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene 
associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may 
also be associated with increased risks for these cancers. Panel testing is now considered a standard of care in 
patients at high risk to carry a genetic mutation such as this one with breast cancer at the age of 45 with a 
negative BRCA1 and 2 mutation. The service is reasonable and 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 the NGS BRCA panel have been met. Therefore, we decided that the Plan has 
to pre-approve the BRCA gene testing with Next Generation Sequencing (NGS).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have intense and complex care needs. The 
Plan denied your request. The Plan says that you are medically stable with no clinical evidence of any unstable 
medical or rehabilitation conditions requiring a skilled nursing facility 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 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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are
necessary. The Plan denied your request. The Plan says the enrollee currently has two (2) trips remaining and
will have exceeded their benefit limit.
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. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 61st trip and
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 60 additional
routine transportation trips.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says medically necessary care is available in-network. 
 
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 
the medical services to be provided by an OON provider.
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 home health will not provide you with the therapy 
you need. The Plan denied your request. The Plan says that you can safely receive the services you need in 
other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for hip replacement. Your medical 
problems are stable. There are no identified problems that need inpatient medical management. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for teeth #21-26 and 28 (D2740), core buildup 
for teeth #21 and 26 (D2950), endodontic therapy for tooth #26 (D3310), and endodontic therapy for tooth #21 
(D3320). 
 
You asked the Plan to pre-approve crowns for teeth #21-26 and 28, core buildup for teeth #21 and 26, 
endodontic therapy for tooth #26, and endodontic therapy for tooth #21. You say that the services are 
necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns for teeth #21-26 and 28 (D2740), core buildup for teeth #21 and 26 (D2950), endodontic therapy for 
tooth #26 (D3310), and endodontic therapy for tooth #21 (D3320).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kevzara. 
 
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 self-administered drugs are not covered. 
 
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 Kevzara.  
 
Benefits for these services 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 Corlanor. 
 
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 self-administered drugs are not covered. 
 
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 Corlanor.  
 
Benefits for these services 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 Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the medication is necessary. The Plan denied your 
request. The Plan says you have a medical only policy which does not include Part D prescription coverage, 
therefore the criteria for self-administered drug coverage has not been met. 
 
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 Trulicity.  
 
Benefits for Trulicity 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial rotation 
unit (L5986). 
 
You asked the Plan to pre-approve the flex-walk system and the multi-axial rotation unit. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says the requested prostheses 
exceed the enrollee's needs. 
 
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 flex-walk system and the multi-
axial rotation unit. Our reviewer says that the criteria for coverage of the requested items have not been met. 
Our physician reviewer found the enrollee has a history of left below the knee amputation and uses a prosthesis 
since 2014.  The enrollee has lost weight and his current prosthesis is noted to be ill fitting.   Review of the 
submitted documentation does not support the need for walking with environmental barriers such as steep or 
slippery surfaces.  Medical necessity cannot be determined. The plan has approved a prosthesis without the 
advanced flex-walk and multi-axial rotation unit. 
 
 
 
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 flex-walk system and the multi-axial rotation unit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a flex-walk system (L5981) and a multi-axial 
rotation unit (L5986).
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 are no medical 
issues that require rehab physician supervision. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for treatment of a pelvic fracture. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record does document 
a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. 
 
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-approvecyclobenzaprine 10mg tablets.You asked the Plan to pre-approvethe cyclobenzaprine tablets. You say that this medication is necessary.The Plan denied your request. The Plan says this oral drug is not covered by Medicare 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-approvecyclobenzaprine 10mg tablets.Benefits for the cyclobenzaprine tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. You asked the Plan to pre-approve the requested services. You say that the enrollee has severe cyclophosphamide toxicity. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the requested treatment. The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee was diagnosed with T-cell leukemia in 2009, and was ordered undergo hyperbaric oxygen therapy as part of his treatment for recurrent gross hematuria secondary to severe cyclophosphamide toxicity. The records do not show that the enrollee has a covered indication for the requested treatment. Therefore, the requested treatment is not medically reasonable or necessary to treat the 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve the TTFT. You say that the requested treatment is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT will be denied as not reasonable and 
necessary for the treatment of recurrent GBM. 
 
We looked at the file and Medicare rules. The records show that the enrollee has recurrent GBM. Based on this 
information, we decided that Medicare rules for coverage of the TTFT have not been met. Therefore, we 
decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870) and insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; second level (CPT Code 22870) 
and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression 
or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has no acute psychiatric symptoms that require 24 hour inpatient 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee in this case. Based upon review the records provided it is not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted. The patient is not shown to be a danger to herself or others. She was cooperative/compliant with treatment while not showing any threats the safety or any aggressive behavior. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveenteral formula (CPT Code B4152 x1890 units).You asked the Plan to pre-approveenteral formula. You say that the services are necessary.The Plan denied your request. The Plan says drinks taken by mouth are not a Medicare covered benefit.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula have not been met. The rules say that enteral nutrition products that are administered orally and related supplies are noncovered, no benefit.Therefore, we decided that the Plan does not have to pre-approveenteral formula (CPT Code B4152 x1890 units)