Persius/hicric huggingface dataset:
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 had a stroke and cannot do rehab at home The 
Plan denied your request. The Plan says your medical condition requires further evaluation and treatment in the 
current acute care hospital. 
 
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 
surgical repair of a hip fracture after a fall, a post-operative stroke, and deep vein thrombosis. Your medical 
problems are stable and you have 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You did not provide a specific argument for coverage. 
The Plan denied your request. The Plan says there is not a compelling reason to provide a ventilator as opposed 
to a BiPAP with a backup rate and average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates that you 
have chronic respiratory failure from chronic obstructive pulmonary disease. The record appears to indicate 
that you were successfully treated with BiPAP.  The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. You could be 
treated with a BiPAP machine with AVAPS capability.  The plan has indicated coverage for such a device is available upon request. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 current facility does not have enough staff to help 
the patient get up and walk. The patient would benefit from IRF care to help him get back to a normal lift after 
his hip fracture. The Plan denied your request. The Plan says the patient's care can be managed at a lower level 
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 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 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 fever and hematuria. Medical problems are stable. 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. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nuwiq injection. 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has hereditary Factor VIII 
deficiency. There are no records indicating diagnosis and rationale for the use of recombinant Factor VIII. The 
Nuwiq is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Nuwiq injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these tests are not included in 
the ESRD rate. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation (RFA). 
 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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that endovenous RFA is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has varicosities in the 
perforating veins. The rules state that the requested service is covered only for the treatment of symptomatic 
varicosities of the lesser or greater saphenous veins and their tributaries. The elements of the coverage criteria 
are not satisfied. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the documentation does not support that the requested portable ventilator is medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive 
pulmonary disease with hypercarbia. The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
bilevel positive airway pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability. Therefore, the enrollee does not meet criteria for the requested device. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit from a chiropractor and waive the copays for 
chiropractic manipulative treatments from February 23, 2022, to March 9, 2022. 
 
You asked the Plan to pay for the office visit and waive the copays for chiropractic manipulative treatments. 
You say that you have to go to the chiropractor because you have chronic pain. The Plan denied your request. 
The Plan says other services, other than manual manipulation, performed by a chiropractor are not covered and 
the copayment for the chiropractic manipulative treatments applied correctly. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 $5 
copayment for in-network Medicare covered chiropractic services. 
 
You have been asked to pay $240 ($220 office visit charge and $20 copay for chiropractic treatments) for the 
denied office visit and chiropractic manipulative treatments. The chiropractic manipulative treatments falls 
within the Chiropractic Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. 
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit or waive the copayment for chiropractic manipulative 
treatments provided from February 23, 2022, to March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee needs to improve her quality of life. 
The Plan denied your request. The Plan says coverage criteria have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. In this case, there were insufficient medical records provided to show 
that the Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-
approve a home ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that this is needed to prevent neutropenic fever. The Plan 
denied your request. The Plan says that the requested use of Neulasta is not supported by the Food & Drug 
Administration (FDA) approved indications or drug compendia. 
 
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 reviewer says that the 
enrollee meets the Medicare criteria for Neulasta. Our physician reviewer found the requested use of Neulasta 
is Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The use of Taxotere is 
intermediate risk of febrile neutropenia. Therefore, the use of Neulasta is safe and effective and otherwise 
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 Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
use of Neulasta.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing aid repair. 
 
You asked the Plan to pre-approve the hearing aid repair. You say that one of your hearing aids needs to be 
repaired. The Plan denied your request. The Plan says hearing aid repair is not a covered benefit. 
 
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 plans coverage rules apply in this case. The Plan offers a 
$500 maximum allowance toward the cost of a hearing aid(s) every year. 
 
We looked at this the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid repair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a hearing aid repair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on March 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that the last time you had seen this member was 2020. 
You also say that at that time the member was insured by Medicare, and since no new information was 
provided by the patient at this visit, the claim was submitted to Medicare as usual. The Plan denied your 
request. The Plan says the rendering provider is a non-participating provider. The Plan also says there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
provider or this facility. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist visit provided on March 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from April 4, 2022, to April 
8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient services. You say that the enrollee's clinical presentation met the 
criteria for inpatient care. The Plan denied your request. The Plan says prior authorization was not obtained by 
the provider or facility. 
 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the inpatient services provided from April 4, 2022, 
to April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that additional PT visits are medically 
necessary. The Plan denied your request. The Plan says the request for six (6) additional physical therapy visits 
does not meet medically necessary and reasonable criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that given the physical therapy treatments already approved, including 
the recently approved ten additional sessions, the records do not support the complexity of the enrollees 
conditions are such that sixteen therapy sessions are required.  Our physician reviewer also found that based on 
the available records the enrollee appears to have improved with therapy to the point of being able to manage 
multiple activities of daily living. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional 
transportation to be approved for coverage. The Plan denied your request. The Plan says your benefit only 
allows 24 trips for this service and you have used all 24 trips. The Plan also says that you have exceeded your 
benefit limit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per 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 transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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.  
 
Review of the file shows that the Plan uses Local Coverage Determinations (LCD) L38920 and L35026 for 
their denial. However, these LCDs are not valid for the enrollees home state of Illinois. Therefore, we cannot 
use these LCDs to substantiate our decision. 
 
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 Truxima. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of monoclonal gammopathy of unknown significance in 
neuropathy with positive anti-myelin-associated glycoprotein antibody. The Food and Drug Administration has 
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.