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

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the enrollee can 
transition to a home program and additional chiropractic visits are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic services. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested chiropractic services. Our physician 
reviewer found the records submitted reveal no evidence of improvement or that further improvement would 
likely occur from continued chiropractic treatments. The requested treatments are maintenance therapy and are 
not supported or allowed by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lisinopril 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Lisinopril for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil 5mg tab 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 the drug in question is not covered under the enrollee's contract under any 
circumstances. 
 
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 Tadalafil 5mg tab for the 
enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the drug is FDA-approved treatment that is 
medically necessary. The Plan denied your request. The Plan says that Spravato must be used in combination 
with an oral antidepressant 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 Spravato. Our physician reviewer found 
that Spravato/Esketamine nasal spray was requested for the treatment of major depressive disorder, recurrent, 
moderate, borderline personality disorder, generalized anxiety disorder, ADHD and ADD. The documentation 
shows that this enrollee has had resistant major depressive disorder. She has had worsening depression rating 
scales. Based on review the records provided, this enrollee does meet the criteria for the use of 
Spravato/Esketamine nasal spray for the treatment of major depressive disorder, recurrent, moderate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Spravato have been met. Therefore, we decided that the Plan has to pre-approve 
Spravato.  
 
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: 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 need the inpatient rehabilitation after spraining your ankle because you are unable to put weight on your right side. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Durvalumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary for non-small cell lung 
cancer. The Plan denied your request. The Plan says that the clinical history and indications submitted fail to 
meet medical necessity criteria. 
 
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 services are medically reasonable and necessary. Our physician reviewer found the enrollee is being 
treated like a stage III NSCLC given a single solitary metastases in a similar area as her tumor. She received 
chemotherapy and radiation and durvalumab is using for consolidation as in stage III disease. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Durvalumab 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 Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the requested Remicade is medically necessary. 
The Plan denied your request. The Plan says the enrollee must try and fail Inflectra and Renflexis first. 
 
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 Remicade. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of 
Rheumatoid arthritis without rheumatoid factor, multiple sites. The Plan requires a trial of drugs Inflectra and 
Renflexis first before they will approve the requested drug. The enrollee has not tried and failed the required 
drugs in this case. The documentation does not support that Renflexis (Infliximab-abda) and Inflectra 
(Infliximab-dyyb) 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
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. You say that the enrollee will need the high level of rehabilitation. 
The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is concern that the enrollee will not be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one. 
 
You asked the Plan to pre-approve Synvisc-one. You say that the requested Synvisc-one is medically 
necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc 
first. 
 
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. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation 
provided, the enrollee is noted to have osteoarthritis in both knees. A request has been made for Synvisc, a 
hyaluronic acid injection, to treat the osteoarthritis. The health plan requires that other forms of hyaluronic acid 
injections be used. 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 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve etoposide. 
 
You asked the Plan to pre-approve etoposide. You say that this is a recommended regimen. The Plan denied 
your request. The Plan says this is not a medically accepted indication. 
 
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 and meets the guidelines listed 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 etoposide. Our reviewer says that the 
criteria for coverage of etoposide have not been met. Our physician reviewer found etoposide is not listed in the 
NCCN Clinical Practice Guidelines in Oncology (NCCN) for the enrollee's specific diagnosis. It is not FDA 
approved for this use. 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of etoposide have not been met. Therefore, we decided that the Plan does not have 
to pre-approve etoposide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (CPT Code L1851). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the knee brace is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been 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 knee orthosis. Our physician 
reviewer found the documentation in the case file does not support that the requested knee orthosis was 
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established 
by the LCD. There is no objective documentation of joint laxity.  
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the knee orthosis (CPT Code L1851).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says that the requested Aranesp is 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 Aranesp. Our reviewer says that the 
requested Aranesp is medically necessary. Our physician reviewer found the enrollee has anemia of Chronic 
Renal Failure and has been prescribed Aranesp which has been denied due to low ferritin. Rationale being that 
the enrollee is iron deficient and iron replacement therapy is indicated before Aranesp can be initiated.  
 
First the ferritin is within the normal range for the lab. Second, other markers such as serum iron and transferrin 
saturation are within normal limits. It is not clear this enrollee is iron deficient and will benefit from iron 
replacement therapy. Based on the documentation provided, Aranesp is indicated as 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 Aranesp have been met. Therefore, we decided that the Plan has to pre-approve 
Aranesp.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) 
provided on March 2, 2020. 
 
You asked the Plan to waive the copayment for MRI. You say that The Plan declared that they cover the 
remaining 20% of most medical costs. The Plan denied your request. The Plan says the copayment amount you 
are being charged is correct. 
 
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 $225 
copayment per day, per provider for in-network MRI tests. 
 
You have been asked to pay $225 copayment for MRI. MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
Magnetic Resonance Imaging (MRI) provided on March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 17, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the medic's advice by not going to emergency because of Covid. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) 
performed on May 29, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told there 
would be cost to you if no polyps were found during the colonoscopy. 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 a $250 
copayment for each Medicare-covered ambulatory surgical center visit. The contract clearly defines a 
diagnostic colonoscopy as a procedure performed, in part, because you've had a previous colonoscopy that 
resulted in removal of polyps. 
 
In this case, the case record documents that you have a history of colon polyps. You have been asked to pay a 
$250 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the "Outpatient surgery" 
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 a diagnostic colonoscopy 
(45378) performed on May 29, 2020.  
 
 
 
 
 
Your complaint about receiving erroneous or misleading information about cost-sharing from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.