Persius/hicric huggingface dataset:
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 you cannot stand alone without help. 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 in the Medicare rules section. 
 
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 
nausea, vomiting, and diarrhea. Medical problems are stable. 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 supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you an additional $20 for eye refractions (92015).

You asked the Plan to reimburse you an additional $20 for eye refractions. You say that you should be
reimbursed an additional $20 for this service. The Plan denied your request. The Plan says that you are
responsible any amount over $75 for out-of-network routine eye exams.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says you are covered for a routine eye exam with no copayment when provided by
an in-network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of eye refractions have been met. Specifically, the Explanation of Benefits related to the service at
issue shows that the rendering doctor is an in-network provider with the Plan. The record shows that you paid a
total of $120 for the services ($25 copayment for an office visit plus a $95 charge for eye refractions). 
The record also shows that you were reimbursed $75 of the $95 charge for the eye refractions. 
This means that the Plan must reimburse you the remaining $20, since services were rendered by an
in-network provider and should not have a copayment. Therefore, we decided that the Plan has to reimburse
you an additional $20 for eye refractions (92015).

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 anticancer treatment with Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee meets criteria for approval for treatment 
with Keytruda. The Plan denied your request. The Plan says this off-label use of Keytruda is not medically 
necessary or supported. 
 
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 Keytruda. Our reviewer says that the 
requested treatment is not medically necessary and reasonable. Our physician reviewer found that the requested 
use of Keytruda is not FDA-approved for the enrollee's diagnosis. The available medical documentation shows 
that, in the case of the the enrollee's tumor, microsatellite instability (MSI)-High was not detected. Neither is 
the use 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve anticancer treatment with Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hearing aid, digital, binaural, item (V5260), hearing aid 
or assistive listening device/supplies/accessories (V5267) and special supplies provided by the physician or 
other qualified health care professional (99070) provided October 14, 2020. 
 
You asked the Plan to pay for the hearing aid, hearing aid or assisted listening device/supplies accessories and 
special supplies. You say that the Plan should pay for the hearing aid. The Plan denied your request. The Plan 
says you did not use a network provider and therefore the services are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when you see a provider in the third-party vendor's network to purchase plan-approved 
hearing aids. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid, hearing aid or assisted listening device/supplies accessories and special supplies 
have not been met. Specifically, the services at issue were not provided by a provider from the Plan's hearing 
benefits vendor. Therefore, we decided that the Plan does not have to pay for the Hearing aid, digital, binaural, 
item (V5260), hearing aid or assistive listening device/supplies/accessories (V5267) and special supplies 
provided by the physician or other qualified health care professional (99070) provided October 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued SNF admission. 
 
You asked the Plan to pre-approve the continued SNF admission. You say that the enrollee is not medically 
steady to go home. The Plan denied your request. The Plan says this request does not meet Medicare guidelines 
because the enrollee no longer requires skilled services, and the continued skilled nursing services are 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 in the Medicare rules section 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 continued SNF admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires 
the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on 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 the continued SNF admission have not been met. Although the enrollee has 
skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to 
pre-approve a continued SNF admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee. 
 
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the member has not tried and failed the preferred step therapy 
drug. 
 
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 Supartz FX. Our reviewer says that 
Supartz FX is not medically reasonable and necessary for the enrollee. The patient has not tried and failed 
Monovisc. There is no indication that the plan's required drug, Monovisc, would likely be less effective and/or 
likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not 
meet step therapy criteria for Supartz FX. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
enrollee 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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucala (J2182). 
 
You asked the Plan to pre-approve Nucala. You say that this is medically necessary. 
 The Plan denied your request. The Plan says this medication is not being prescribed for a medically accepted 
indication. 
 
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 Nucala. Our reviewer says that the 
criteria for coverage of Nucala have not been met. Our physician reviewer found Nucala is not FDA-approved 
for the enrollee's diagnosis as there is no documentation that the enrollee has had the hypereosinophilic 
syndrome for at least 6 months duration. The use of Nucala for hypereosinophilic syndrome present for less 
than 6 months duration is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The requested use is not documented to be safe, 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 Nucala have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nucala (J2182).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), four gingival
irrigations (D4921 x4), and extraction (D7210).

You asked the Plan to pay for the adjunctive pre-diagnostic test, gingival irrigations, and extraction. You say
that you believe these services should be covered. The Plan denied your request. The Plan says the adjunctive
pre-diagnostic test and gingival irrigations are not covered benefits under your dental plan. The Plan also says
that you are responsible for 50% of the allowed amount for the extraction, which is $73.50 ($147.00 allowed
amount - $73.50 coinsurance).

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 adjunctive pre-diagnostic test
(D0431) and gingival irrigation (D4921) are not among those covered under this benefit. The contract also
clearly states that you are responsible for a 50% coinsurance for each extraction (D7210). Therefore, we
decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), four gingival
irrigations (D4921 x4), and extraction (D7210).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not require daily skilled services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, her lungs 
were clear, and she was treated for pain. There are no identifiable skilled nursing service needs. Regarding 
rehab services, the enrollee was at a contact guard assist level with functional mobility. Although there are 
identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a 
daily basis. The enrollee does 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auryxia.

You asked the Plan to pre-approve Auryxia. You say that this drug will help control the enrollee's serum
phosphorus levels. The Plan denied your request. The Plan says this medication does not fall under 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 Auryxia.

Benefits for Auryxia 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for immune globulin (Flebogamma) and
intravenous (IV) therapy administration services.

You asked the Plan to waive the cost-sharing for Part B drug and IV administration services. You say that no
one told you how much these services would cost, and this is too much money. The Plan denied your request.
The Plan says the cost-sharing amounts you are being charged are 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 20%
coinsurance for Part B drug and $150 copayment for IV administration services. The allowed amount of the
Part B drug is $3,327.56, resulting in a coinsurance amount of $665.51. For the IV administration services you
have been asked to pay $62.76, which is less than the $150 copayment for non-surgical outpatient hospital
services. Your total cost-sharing obligation is therefore $728.27.

You have been asked to pay 20% coinsurance for Part B drug and less than $150 copayment for IV
administration services. Part B drug and IV administration services fall within the "Medicare Part B
Prescription Drugs" and "Outpatient Hospital Services" 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 cost-sharing for immune globulin (Flebogamma) and intravenous (IV) therapy administration
services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission and care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not recovering and cannot walk and need 
rehabilitation services. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section of this letter 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 that you are a 76 year old male status post 
motor vehicle accident with multiple injuries, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) 
placement, critical illness myopathy, and COVID-19 pneumonia, currently in an inpatient rehabilitation facility 
(IRF). You have identifiable skilled nursing and therapy service needs. However, 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 admission and care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on November 3, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (81003, 87086, G0463) provided by an OON provider.

You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were non-emergent and there were network providers
available.

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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided
that the Plan does not have to pay for outpatient services (81003, 87086, G0463) provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625). 
 
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 sacroiliac joint radiofrequency ablation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered an experimental procedure because of the wide 
variation in efficacy reported in the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (64625).