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

 
We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed and Pembrolizumab. 
 
You asked the Plan to pre-approve the Carboplatin, Pemetrexed and Pembrolizumab. You say that you would 
like reconsideration based on the clinical notes submitted. The Plan denied your request. The Plan says these 
drugs are not medically necessary. 
 
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 the Carboplatin, Pemetrexed and 
Pembrolizumab. Our reviewer says that the requested combination is not FDA or compendium supported 
unless there are no actionable ALK or EGFR mutations. Our physician reviewer found the submitted 
documentation does not indicate any testing for ALK or EGFR mutations. 
 
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 Carboplatin, Pemetrexed and Pembrolizumab have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed and Pembrolizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high strength lightweight wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. 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. 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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this request appears to exceed the enrollee's needs. There is no evidence that the enrollee can 
participate in activities that cannot be performed in a standard or lightweight wheelchair or requires special 
seating measurements that cannot be accommodated in a standard or lightweight wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high strength lightweight wheelchair for the enrollee.
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 enrollee needs to be dismissed from the hospital. 
You say that the enrollee still needs help in eating orally and in cleaning himself. The Plan denied your request. 
The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could 
receive 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
The enrollee was admitted for complications (including infection and bleeding) associated with surgical 
removal of the mandible because of osteonecrosis. The enrollee's medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does 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 the enrollee 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: 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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
The Plan says that the enrollee can safely receive the services needed 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
The enrollee was admitted for respiratory failure and a COVID-19 infection. The enrollee's medical conditions 
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The enrollee does 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 the enrollee 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physician services provided. 
 
You asked the Plan to waive the deductible for the physician services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received physician services on the date of service at issue in this appeal. The 
Plan says that the correct amount has applied towards your deductible per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible that must be met before the Plan will pay their share 
for Physician/Practitioner services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is $500 deductible that must be met before the Plan will pay their share for Physician/Practitioner 
services. This cost sharing is a contractual obligation that had not been met at the time the physician services 
was received. Therefore, we decided that the Plan does not have to waive the deductible for 
the physician services provided.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by non-certified 
provider. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires total parental 
nutrition. The Plan denied your request. The Plan says home health services that is not from a Medicare 
certified home health agency is not covered by Medicare or the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The requested provider in this case is not eligible to provide services by the Plan or Original Medicare. 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 the requested services. Therefore, we decided that the 
Plan does not have to pre-approve home health services to be provided by non-certified provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the information submitted doesn't meet the medical necessity guidelines for 
coverage. 
 
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 Durolane. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has osteoarthritis of the left 
knee and has tried using Aleve, Tylenol, and intra-articular steroid injections for the pain. The Plan requires a 
trial of the drugs Orthovisc and Monovisc before they will approve the requested drug. The enrollee has not 
tried and failed these required drugs. The records provided did not demonstrate that these required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the requested drug is not 
considered medically reasonable and 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. 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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed one viscosupplemental treatment such as Orthovisc and Monovisc.  Step therapy, as outlined by the 
plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons 
these medications were not considered. Without the support of the documentation, Supartz FX is not approved 
as step criteria have not been 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX injection for the enrollee.
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 ongoing care for skilled nursing or skilled rehab needs can be met in a 
lower level of care. 
 
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 is stabilizing but will require additional short term acute care services 
which can safely be administered at the current facility. The enrollee does not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH 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. Transfer to a lower level of care may be considered when 
treatment has 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued CPAP rental. 
 
You asked the Plan to pre-approve the continued services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no clinical evidence to support the medical necessity of continued 
use. 
 
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 continued services. Our reviewer 
says that the requested continuation of services is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the compliance summary shows use of the device does not meet the 
minimum requirements of at least 70% of nights with at least 4 hours/night. However, it also appears the device 
is not effective when used, because the AHI remained abnormal at 9.7. There has been no follow-up clinical 
visit to address these issues. Continued CPAP is considered not medically necessary because it is ineffective 
and not being used sufficiently. 
 
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 continued services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued CPAP rental.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full length bed side rails. 
 
You asked the Plan to pre-approve full length bed side rails. You say that the enrollee needs bedside rails to 
prevent falls. The Plan denied your request. The Plan says side rails used as a restraint to prevent falls or 
wandering will be considered not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The full side bed rails requested are a self-pay non-DME item available for purchase in retail or hardware 
stores and do not require a prescription. Therefore, we decided that the Plan does not have to pre-approve full 
length bed side rails.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the vision services you received on 
September 16, 2020. 
 
You asked the Plan to waive the cost share. You say that you had the same thing done last year and didn't have 
to pay anything. The Plan denied your request. The Plan says you are responsible for the cost share. 
 
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 20% 
coinsurance for diagnostic tests and procedures. Your contract also says that you must pay a $35 copayment for 
each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. 
 
Review of the file shows that you had a corneal topography and an eye exam on September 16, 2020. You have 
been asked to pay a 20% coinsurance for the corneal topography, totaling $7.66. This services falls within the 
outpatient diagnostic tests benefit category. You have also been asked to pay a $35 copayment for the eye 
exam. 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 cost share for the vision services you received on September 
16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider.
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 necesasry. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health, and home physical therapy. 
 
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 an 
infection of the foot and had a partial amputation. 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).