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

We decided that the Plan does not have to pre-approve NPlate. 
 
You asked the Plan to pre-approve the NPlate. You say that you would like reconsideration because this 
medication is medically necessary. The Plan denied your request. The Plan says this dose exceeds what is 
indicated by the accepted standards of medical practice. 
 
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 NPlate. Our reviewer says that 
Medicare approved compendia support the use of the requested medication for individuals with inadequate 
response to corticosteroids, immunoglobulins, or splenectomy. Review of the submitted documentation notes 
the enrollee had platelet counts above 50,000 throughout the course of treatment with corticosteroids. Our 
physician reviewer found medical necessity of the requested medication 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 NPlate have not been met. Therefore, we decided that the Plan does not 
have to pre-approve NPlate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full upper and lower denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered once every five years. 
 
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. The Plan covers dentures once 
every five years. 
 
Dentures were last received less than five years ago on June 10, 2019. Based on this information, we decided 
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a full upper and lower denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is deemed medically necessary for 
your health. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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 would like reconsideration because these 
services are medically necessary. The Plan denied your request. The Plan says you can safely receive the 
necessary care in another setting. 
 
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 there are no identified problems that need inpatient medical management. There are 
no complex nursing or rehabilitation needs. 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 continued services. You say that the enrollee says she is bedridden and not 
able to move much. The Plan denied your request. The Plan says there are no skilled needs at this time. 
 
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. 
 
Continued SNF services beyond November 20, 2020 was requested. 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 continued services. Our physician reviewer found that the most recent notes 
indicate that you require stand by assistance to contact guard assistance for transfers and bed mobility. You 
require moderate assistance with activities of daily living and are able to walk up to 75 feet using a walker. You 
are medically stable and do not have any complex daily wound care, parental medications, or require care for a 
feeding tube. You do not require skilled therapy to establish a safe and effective maintenance program. As a 
practical matter, you do not require any skilled services on an inpatient basis, at a SNF level of 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 continued 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve additional mental health services. 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 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.  
 
Review of the file shows that the plan has approved 8 additional visits with this provider. The plan has stated 
that once the 8 visits are exhausted, the provider can submit updated medical records with a treatment 
extension request for review of additional visits. Therefore, we decided that the Plan does not have to pre-
approve additional mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve HBO therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277) and Physician attendance and supervision of hyperbaric oxygen therapy (99183). You say that 
HBO therapy is medically necessary for the enrollee's non-healing wounds. The Plan denied your request. The 
Plan says that the enrollee's wounds have improved with treatment and HBO is not covered for the treatment of 
chronic peripheral vascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 hyperbaric oxygen under pressure, full 
body chamber, per 30-minute interval (G0277) and Physician attendance and supervision of hyperbaric oxygen 
therapy (99183). Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the wound has been present for extended period and has 
failed all therapies. HBO therapy is indicated due to the need documented wounds and associated infection. 
The denial is overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) and Physician attendance and supervision of hyperbaric oxygen therapy (99183) have been met. 
Therefore, we decided that the Plan has to pre-approve HBO therapy.  
 
 
 
 
 
 
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 Neulasta. 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the enrollee's 
regimen has a low risk of febrile neutropenia. 
 
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 Neulasta. Our physician reviewer found 
that this request is for Neulasta to treat the enrollee who is receiving Carboplatin/Pemetrexed for adjuvant 
treatment of resected non-small cell lung cancer. The drug is being used for primary prevention of febrile 
neutropenia. There is no documented history of febrile neutropenia. The chemotherapy regimen is not listed as 
high or intermediate risk for febrile neutropenia.  
 
 
The FDA and compendia support the use of the drug for prevention of febrile neutropenia in the setting of 
chemotherapy with clinically significant or high risk or intermediate risk if there are other risk factors. 
Therefore, the drug is not FDA approved for the requested use. The drug is not supported in any of the CMS 
compendia for the supported use. The use is not listed as not indicated, not supported or not recommended in 
any of the compendia. Therefore, the documentation does not support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this 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 Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care from November 21, 2020, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care from November 21, 2020, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit securement package for the enrollee. 
 
You asked the Plan to pre-approve a transit securement package. You say that this is necessary for the safe 
transport of the patient and/or wheelchair. The Plan denied your request. The Plan says that this 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.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a transit securement package for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve the Xiidra eye drops. You say that this medication is medically necessary. 
The Plan denied your request. The Plan says this self-administered 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-approve Xiidra eye drops.  
 
Benefits for the Xiidra eye drops 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for confusion and a bladder infection. Medical problems are stable. There are no identified problems 
that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient 
does 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 this patient 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requestedphysician's services.You asked the Plan to pre-approve the physician's services.You say that you continue to have muscle deterioration despite receiving years of treatment in maximum doses you believe that this physician could help in your current state before it would be too late. The Plan denied your request. The Plan says the service is available within the network at a non-tertiary level of care.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 physician's services.Our reviewer says that the requested physician's services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no clinical rationale for continued tertiary care services.The documentation indicates that the non-tertiary rheumatologist office confirmed that the initial authorized referral to the tertiary physician was only for second opinion that was done on August 27, 2020, and that this physician can manage your current 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 physician's services to be provided by the requested physicianhave not been met. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested physician.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion of Zoledronic Acid (J3489). 
 
You asked the Plan to pre-approve the home infusion service. You say that the service is medically necessary. 
The Plan denied your request. The Plan says records do not support the need for home infusion. 
 
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 home infusion service. Our 
reviewer says that the home infusion is not medically necessary. Our physician reviewer found the enrollee is 
not currently receiving home health services. The records show no documented reason why home infusion is 
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 home infusion service have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home infusion of Zoledronic Acid (J3489).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 improving, but they require additional short term acute care 
services of less than 25 days which can be completed at the current facility. The patient does not require 
services at the LTACH that are not already available at the current setting. There are no services at the current 
facility that the patient requires that are not already available and covered at the current facility. Therefore, this 
request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level 
of care may be considered once the patient is more stable and treatment is completed. 
 
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 LTACH services.