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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) on March 
13, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that, because your 
emergency room visit was a consequence of narcotic administration during your back surgery, you should not 
be liable. The Plan denied your request. The Plan says the correct copayment was 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 an $80 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay an $80 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency care" 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 an 
emergency room visit (99284) on March 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Denosumab. 
 
You asked the Plan to pre-approve the Denosumab. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says the member does not meet coverage 
criteria for 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 Denosumab. Our reviewer says that 
the documentation does not include a discussion regarding previous treatments trialed or current laboratory 
studies.  Medicare compendia do not support the use of Denosumab for the treatment of osteopenia. Our 
physician reviewer found without the support of the literature, medical necessity cannot be determined. 
 
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 Denosumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Denosumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays and oral evaluation provided on October 
7, 2019. 
 
You asked the Plan to pay for the intraoral x-rays and oral evaluation. You say that you didn't understand the 
contract status of the provider. The Plan denied your request. The Plan says out-of-network dental services are 
not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral x-rays and oral evaluation provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick external catheter. 
 
You asked the Plan to pre-approve the requested item. You say that you get wet at night from urine and have 
bed sores. The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and the rules. Medical supplies, such as catheters, are not considered durable within the 
meaning of the definition. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Purewick external catheter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBO therapy). 
 
You asked the Plan to pre-approve HBO therapy. You say that you have an injured hand that has not been able 
to heal. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because you do not have a covered indication for hyperbaric oxygen therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered for 
the indications described above.   
 
We looked at the file and Medicare rules. The diagnosis for which your treating provider has requested 
hyperbaric oxygen therapy is not among those covered by Medicare. Based on this information, we decided 
that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hyperbaric oxygen therapy (HBO therapy).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested hospital bed. You say that the bed is needed so caregivers 
won't hurt themselves. The Plan denied your request. The Plan says a total electric bed is not covered. 
 
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 pre-approve a total electric hospital 
bed.
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 the services are necessary.  The Plan denied your request.  The Plan says based on the documentation provided, coverage criteria has not been met.

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 necessary based on Medicare guidelines.  Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care.  The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF.  The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires or can fully tolerate an intensive rehabilitation therapy program provided in an IRF.

We looked at the 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage (A0170). 
 
You asked the Plan to pre-approve additional Logisticare mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
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 60 one-way transportation trips per calendar year when each one-way trip does not 
exceed 75 miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional Logisticare mileage (A0170).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 50 one-way transportation 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. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has previously treated 
progressive squamous cell cancer of the esophagus. The tumor PDL1 CPS is less than one. There is no 
information given regarding microsatellite instability (MSI) or mismatch repair (MMR) testing. The requested 
use is not FDA-approved or supported by Medicare-approved compendia. The services are therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
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 IGRT is generally not needed to treat 
skin cancers unless deep structures are being treated. There is no plausible rationale for the use of IGRT for this 
enrollee. It is not the standard of care for the enrollee's diagnosis and is not reasonable or medically necessary 
at this time. 
 
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 image-guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services 
for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation has been consistently 
recommended by the medical team that is involved in the members care. The Plan denied your request. The 
Plan says that that the enrollee has no complex medical needs that require intensive rehab and does not need to 
be directly under the care of a doctor supervision 24 hours a day, 7 days a week. 
 
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 found to be medically reasonable and necessary for this enrollee. The complexity of the 
enrollee's nursing, medical and rehabilitation needs warrants a course of acute hospital inpatient services with 
an interdisciplinary approach to rehabilitation care. The patient requires treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
There a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
meets 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta. 
 
You asked the Plan to pre-approve Vyzulta. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has 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 Vyzulta.  
 
Benefits for Vyzulta 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 use of OPDIVO (to be used in combination with 
YERVOY). 
 
You asked the Plan to pre-approve OPDIVO. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for this drug is correct, because the enrollee has been previously 
treated with OPDIVO and progressed. 
 
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 OPDIVO. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of OPDIVO. Our physician reviewer found 
the requested use of OPDIVO is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. 
The enrollee had progression of disease on prior OPDIVO. Also, the plan for combination with ipilimumab is 
for first line therapy and not for subsequent therapy. The requested use of OPDIVO is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OPDIVO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of OPDIVO (to be used in combination with YERVOY).
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 the enrollee's life is in jeopardy and that 
he cannot go to a lower level of care due to life threatening conditions. The appellant says that the enrollee 
needs constant monitoring that a lower level of care facility could not handle. The Plan denied your request. 
The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the care 
needed can be provided in the current inpatient hospital. 
 
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 enrollee's complex medical needs are being met in the current acute setting at this 
time. Therefore, transfer to a LTACH is not medically necessary. The enrollee is receiving appropriate care at 
the current acute care facility. The review has determined that the enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee. The enrollee is receiving appropriate care at the 
current acute care 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel (J9264) and Neulasta (J2505). 
 
You asked the Plan to pre-approve Paclitaxel and Neulasta. You say that Paclitaxel and Neulasta are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Paclitaxel and Neulasta. Our reviewer 
says that these drugs are not medically necessary. Our physician reviewer found these drugs are not FDA 
approved for the enrollee's diagnosis. Their use in this application is not supported by the available literature or 
Medicare approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Paclitaxel and Neulasta have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Paclitaxel (J9264) and Neulasta (J2505).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Talicia Cap. 
 
You asked the Plan to pre-approve Talicia Cap. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Talicia Cap.  
 
Benefits for Talicia Cap 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular embolization. 
 
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 vascular embolization is covered when specific 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of other 
specified conditions associated with female genital organs and menstrual cycle. She has pain, pressure, and a 
heaviness sensation in the pelvis. A CT scan showed pelvic varices with suggestion of pelvic congestion 
syndrome (PCS). It is documented that the cause of the enrollee's pelvic pain could be multifactorial. There is 
no documentation of a pelvic examination, whether there are vulvar varices, and what conservative measures 
have been tried. The documentation does not demonstrate that the requested embolization of pelvic varices is 
medically reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vascular embolization.