Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a powered pressure-
reducing air mattress for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the alternative would be returning to the PCP for further evaluation, treatment, and a 
discussion of alternatives. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 services. Our reviewer says that the 
requested items are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not indicate that the enrollee requires frequent or potentially immediate changes in position while in bed. 
The documentation does not indicate that the enrollee would be able to operate bed controls. There is no 
evidence of ulcers. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a semi-electric hospital bed and a powered pressure-reducing air mattress for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment only in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $50 copayment charged for physician hearing services 
provided on July 30, 2020. 
 
You asked the Plan to waive this copayment. You say that your copayment should only be $40. The Plan 
denied your request. The Plan says the medical records show you had a hearing visit and tinnitus test. This 
requires a $40 copayment for the office visit and a $10 copayment for an outpatient diagnostic service. 
 
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 $40 
copayment for hearing services and a $10 copayment for outpatient diagnostic services. 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 $50 copayment charged for physician hearing services provided on July 30, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary to help get stronger. 
The Plan denied your request. The Plan says a lower level of care would be more appropriate. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically, and is 
residing at home. You do not  require skilled nursing and/or skilled therapy services on a daily basis. You are 
medically stable  and can receive further rehab services at a lower level of care. Although further rehab services 
would be appropriate to improve function, as a practical matter, the daily skilled services can be provided at a 
lower level of care than a skilled nursing 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine, non-emergent transportation to your neurologist 
appointments. 
 
You asked the Plan to pre-approve the routine, non-emergent transportation. The Plan denied your request. The 
Plan says these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the Plan does not have 
a routine, non-emergent transportation benefit. Medicare does not cover routine, non-emergent transportation. 
Based on this information, we decided that the Medicare rules for coverage of the routine, non-emergent 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine, 
non-emergent transportation to your neurologist appointments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the services needed could be provided in another setting. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab Xgeva Injection 120MG. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says step therapy encourages the member to try the Plan's  preferred, equally effective 
drug(s): intravenous pamidronate or zoledronic acid. 
 
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 medication. Our physician reviewer 
found the review indicates that the Plan requires a trial of drug intravenous pamidronate OR zoledronic acid 
before they will approve the requested drug. In this case, the patient has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plan?s required drug(s) would likely be less 
effective and/or likely have adverse effects for the 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Denosumab Xgeva Injection 120MG.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Therapy (G6002). 
 
You asked the Plan to pre-approve the proton beam therapy. You say that Proton Beam therapy is medically 
necessary. The Plan denied your request. The Plan says this application is considered investigational and is not 
covered. 
 
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 proton beam therapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while proton therapy for prostate cancer is no longer considered experimental, it 
remains unclear if there would be any clinical benefit in this case to use proton therapy instead of standard 
IMRT treatment. The American Society for Radiation Oncology (ASTRO) and National Comprehensive 
Cancer Network (NCCN) guidelines do not yet recommend routine use of Proton therapy for prostate cancer 
outside of clinical trials. 
 
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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Proton Beam Therapy (G6002).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the spinal cord stimulator is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a trial of a spinal cord stimulator is covered when 
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 the spinal cord stimulator. Our reviewer 
says that the spinal cord stimulator is not medically necessary. Our physician reviewer found the enrollee does 
 
 
not have any prior spine surgery, Complex Regional Pain syndrome, post herpetic neuraglia or any other 
evidence based indication for the stimulator. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator (63650).
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 these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you have exhausted the number of allowable routine 
trips for the calendar year. 
 
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 trips per calendar 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dynamic adjustable wrist extension / flexion device 
(E1805 x12), dynamic adjustable finger extension/flexion device (E1825 x3), and dynamic adjustable elbow 
extension/flexion device (E1800 x3). 
 
You asked the Plan to pre-approve a dynamic adjustable wrist extension / flexion device, dynamic adjustable 
finger extension/flexion device, and dynamic adjustable elbow extension/flexion device. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
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 a dynamic adjustable wrist extension / 
flexion device, dynamic adjustable finger extension/flexion device, and dynamic adjustable elbow 
extension/flexion device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found based on the medical records provided 
there is no documentation that the dynamic adjustable finger extension/flexion device, dynamic adjustable 
elbow extension/flexion device and dynamic adjustable wrist extension/flexion device at issue in this case are 
medically reasonable and necessary. Although the medical records clearly document the enrollee's hand and 
upper extremity weakness there is no documentation in the medical records as to the necessity or use of the 
requested devices. Despite a letter dated October 30, 2020 stating the enrollee is able to perform her activities 
of daily living with the devices, the medical records do not support this statement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a dynamic adjustable wrist extension / flexion device, dynamic adjustable finger 
 
 
extension/flexion device, and dynamic adjustable elbow extension/flexion device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a dynamic adjustable wrist extension / flexion device 
(E1805 x12), dynamic adjustable finger extension/flexion device (E1825 x3), and dynamic adjustable elbow 
extension/flexion device (E1800 x3).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intron A injections. 
 
You asked the Plan to pre-approve Intron A. You say that the service is medically necessary to treat the 
enrollee's condition. The Plan denied your request. The Plan says the request for the Part B drug does not meet 
medical necessity requirements. 
 
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 Intron A. Our reviewer says that Intron 
A is not medically necessary to treat the enrollee's condition. Our physician reviewer found Intron A is not 
FDA approved to treat bladder cancer. The requested use is not supported in any of the CMS approved 
compendia. They also did not find any supporting citations in a PubMed search and the use for Intron A is not 
supported or not recommended in any of the 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 Intron A have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Intron A injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's condition can be managed at an assisted living facility with home 
health services. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee has stabilized medically 
and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled 
therapy services on a daily basis. he is medically stable and can receive further rehab services at a lower level 
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
daily skilled services can be provided at a lower level of care than a skilled nursing 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria has not been met. 
 
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 second opinion to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Vectibix (panitumumab). 
 
You asked the Plan to pre-approve the Vectibix treatment. You say that the enrollee is not able to tolerate 
Folfox and is being put on 5-FU and panitumumab based on the phase II PANDA trial in the elderly. The Plan 
denied your request. The Plan says the use of the requested medication for newly diagnosed metastatic colon 
cancer with fluorouracil is not currently supported and is not covered. 
 
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 Vectibix treatment. Our reviewer 
says that the requested use of Vectibix is not considered reasonable and necessary. Our physician reviewer 
found the enrollee has metastatic colon cancer. Use of this treatment requires that the cancer be KRAS/NRAS 
wild-type status. In this case, the status of these genes is unknown. As such, this treatment is not 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 Vectibix treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Vectibix (panitumumab).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).