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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is necessary because the enrollee's diabetes is not controlled. 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Erbitux intravenous solution (250mg/M2 every two weeks) 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 as this drug is not being used for a medically accepted indication, it cannot be 
approved. 
 
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 per the NCCN 
compendia, erbitux is approved with Folfox for KRAS/NRAS wildtype left sided colon cancer metastatic 
disease. The criteria is 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Erbitux intravenous solution (250mg/M2 every two weeks) for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit rendered on July 7, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were told there would be no 
copayment. The Plan denied your request. The Plan says the copayment was applied 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 a $15 
copayment for each primary care doctor office visit for Medicare-covered services.  
 
Review of the file shows that you had a primary care office visit on July 7, 2020. The services were related to 
soreness in the armpit area and fall outside of the scope of an annual wellness exam. You have been asked to 
pay a $15 copayment for these services. These services fall within the primary care doctor office visit for 
Medicare-covered services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office 
visit rendered on July 7, 2020.
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 you disagree with the denial. 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 NYHA Class III 
congestive heart failure with recovered left ventricular ejection fraction (LVEF of 55 percent) requiring 
hospital admission. In this circumstance, therapy change based on data obtained from a CardioMEMs device 
has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared 
to standard medical therapy. The CardioMEMs is not the standard of care and is considered experimental in 
nature. The services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
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 the SNF services. You say that the enrollee meets all of the requirements for 
coverage of SNF care. The Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the limited documentation submitted 
is of insufficient quality and quantity to show that the enrollee qualifies for SNF services.  The enrollee does 
not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
 
 
 
 
 
 
 
 
 
 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the enrollee will benefit from and improve 
with LTACH management. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be more stable but requires additional short-term acute care 
services which can safely be administered at the current facility. The patient does not require services at the 
LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary. Transfer may be considered when treatment has completed and when a 
lower level of care is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be more stable and improving on treatment but requires 
additional short-term acute care services which can safely be administered at the current facility. The patient 
does not require services at the LTACH that are not already available at the current facility. 
2. There are no services at the LTACH that the patient requires that are not already available and covered at the 
current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for total electric hospital bed (E0297) on March 16, 2020 to May 
28, 2020. 
 
You asked the Plan to pay for the electric hospital bed. You say that you would like the charges reconsidered. 
The Plan denied your request. The Plan says a total electric hospital bed (E0265, E0266, E0296, or E0297) are 
not covered; the height adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for total electric hospital bed 
(E0297) on March 16, 2020 to May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and extractions to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve consultation and extractions to be provided by an oral surgeon. 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 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 
consultation and extractions to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says rehab needs are not complex, and do not require an interdisciplinary approach with 
multiple specialists. 
 
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 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 
cardiomyopathy. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
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. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation 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. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be more stable but requires additional short-term acute care 
services which can safely be administered at the current facility. The patient does not require services at the 
LTACH that are not already available at the current facility. In addition, there are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility. Transfer may be 
considered when treatment has completed at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injection, denosumab (J0897) therapeutic, prophylactic, or diagnostic injection (96372) provided August 19, 2020.

You asked the Plan to waive the copayment for the injection services. You say that you were told that you would not have a copay. This is a hardship for you at this time and you hope the copay will be waived. The Plan denied your request. The Plan says the claim was processed and the correct cost shares were applied.

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 20% coinsurance for each Medicare covered Part B drugs and $335 copayment for Medicare covered surgery or other services provided at an outpatient hospital. 

You have been asked to pay $292.94 ($238.81 + $54.13) for the injection services. The injection services fall within the Medicare Part B Prescription Drugs and Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for injection, denosumab (J0897) therapeutic, prophylactic, or diagnostic injection (96372) provided August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
reportedly has COPD requiring supplemental oxygen. The enrollee is reportedly on BiPAP, but there are no 
medical records or compliance data on BiPAP use. There is no documentation of CO2 retention. There is no 
documented failure of BiPAP. Advanced BiPAP devices can provide the AVAPS mode of support, and this has 
not been tried. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 3, 2020, and August 25, 2020, provided by an out-of-network provider.

You asked the Plan to pay for the out-of-network services. You say that you were on hospice at the time. The Plan denied your request. The Plan says the services could have been scheduled with a plan provider.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. The records indicate that you were not on hospice at the time the services were provided. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 3, 2020, and August 25, 2020, provided by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomographic angiography (CTA) head. 
 
You asked the Plan to pre-approve a computed tomographic angiography, head, with contrast material(s), 
including non-contrast images, if performed, and image postprocessing (70496). You say that the enrollee 
needs a CTA because you suspect a bulging weak spot in the wall of a blood vessel. The Plan denied your 
request. The Plan says that additional imaging is not supported without a clear reason. 
 
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 a computed tomographic angiography, 
head, with contrast material(s), including non-contrast images, if performed, and image postprocessing 
(70496). Our reviewer says that the CTA is reasonable and medically necessary. Our physician reviewer found 
it would be clinically prudent and otherwise consistent with the generally accepted standards of care for the 
member to undergo a follow-up CTA of the head in this clinical circumstance to determine if the member has 
an aneurysm (and if there had been growth) versus atherosclerotic calcification. The results of this study do 
have the potential to lead to changes in the treatment/management of the member's condition. In as much it can 
be said that the proposed study would be reasonable and necessary for the member-and therefore eligible for 
coverage. 
 
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 computed tomographic angiography, head, with contrast material(s), including 
non-contrast images, if performed, and image postprocessing (70496) have been met. Therefore, we decided 
that the Plan has to pre-approve computed tomographic angiography (CTA) head.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ontruzant 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 step therapy guidelines were not followed. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not 
contain documentation that Herceptin, Trazimera, or Kanjinti have been tried and failed. The documentation 
does not support that Herceptin, Trazimera, or Kanjinti 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ontruzant for the enrollee.