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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would not be safe if they are discharged 
home without medical supervision. You say that the enrollee's needs to be in a SNF to regain their strength. 
The Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says that the 100-day SNF benefit was exhausted on 
January 24, 2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. The Plan says the enrollee has exhausted their 100-day SNF benefit, but 
discharge days do not count toward covered SNF days. This means that as of January 24, 2023, the enrollee has 
only used 97 days of the 100-day SNF benefit. Therefore, we decided that the Plan has to pre-approve SNF 
care. 
   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 glucose monitoring system. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 glucose monitoring system. You say that the enrollee 
has a severe fear of injection, therefore cannot use the conventional meter. The Plan denied your request. The 
Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the a Freestyle Libre 2 glucose monitoring system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2 glucose monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stand up walker. 
 You asked the Plan to pre-approve a stand up walker. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a walker is covered for the indications established in 
the applicable LCD. 
 
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 stand up walker. Our reviewer says 
that the requested walker is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not reveal that the enrolled has tried and failed a standard walker, therefore a heavy duty 
walker with seat is not medically reasonable or necessary per L33791. 
 
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 stand up walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a stand up walker.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria (J1602). 
 
You asked the Plan to pre-approve Simponi Aria. You say that Simponi Aria is medically necessary. The Plan 
denied your request. The Plan says a trial of Enbrel, Humira, Kevzara, Rinvoq, Xeljanz or Xeljanz XR is 
required before alternatives can be considered. 
 
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 Simponi Aria. Our reviewer says that 
this drug is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective 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 Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria (J1602).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair (E0240). 
 
You asked the Plan to pre-approve a bath/shower chair. You say that you need the requested bath chair because 
you have a broken right ankle, and it is impossible to take a shower or stand. The Plan denied your request. The 
Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair (E0240).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinvanti (J0185) Palonosetron (J2469), Nivolumab 
(J9299), 5-FU (J9190), Leucovorin (J0640), 
Irinotecan (J9206), Oxaliplatin (J9263) and Dexamethasone (J8540). 
 
You asked the Plan to pre-approve the chemotherapy regimen. You say that the requested regimen is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested regimen is 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 chemotherapy regimen. Our 
reviewer says that the requested chemotherapy regimen is not medically necessary. Our physician reviewer 
found the Food and Drug Administration (FDA) has not stated that the requested chemotherapeutic regimen is 
indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the enrollee's clinical situation. The reviewer 
found no literature from Medicare approved cancer journals were submitted for review. Therefore, the reviewer 
found that the requested chemotherapy regimen is not medically reasonable and necessary. The reviewer also 
found that since the chemotherapeutic regimen is not indicated, the concomitant supportive care is also not 
indicated. 
 
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 chemotherapy regimen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cinvanti (J0185) Palonosetron (J2469), Nivolumab (J9299), 5-FU (J9190), 
Leucovorin (J0640), 
Irinotecan (J9206), Oxaliplatin (J9263) and Dexamethasone (J8540).
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Actemra. Our reviewer says that the 
services are medically necessary. Our physician reviewer found step therapy may only be applied to new 
prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected 
medication. As records indicate the enrollee has been actively receiving Actemra since February 2020, step 
therapy rules do not apply. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra have been met. Therefore, we decided that the Plan has to pre-approve 
Actemra.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0853), detachable 
armrest (E0973), manual swingaway (E1028), and group 34 sealed lead acid battery (E2359). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. The Plan denied your request. 
The Plan says there is no diagnosis to meet group 3 power wheelchair coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
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 group 3 power wheelchair and 
accessories. Our reviewer says that the enrollee does not meet the coverage criteria for a group 3 power 
wheelchair and accessories. Our physician reviewer found the available clinical documentation in the case file 
does not support that the enrollees mobility limitation is due to a neurological condition, myopathy, or 
congenital skeletal deformity. 
 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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0853), detachable armrest 
(E0973), manual swingaway (E1028), and group 34 sealed lead acid battery (E2359).
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 require an interdisciplinary therapy program in 
maximize their rehab potential. The Plan denied your request. The Plan says you can be redirected to a lower 
level of care such as a skilled nursing facility. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with lower extremity osteomyelitis and underwent operative intervention. The record indicates 
that the enrollee is improving but still requires acute care services before transitioning to a lower level of care. 
The enrollee continues to receive acute care services, and these have not been denied. The medical record does 
not indicate that the enrollee requires services that they are not currently receiving but that would be available 
at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 
recommended. 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron hydrochloride HCL. 
 You asked the Plan to pre-approve Palonosetron HCL. The Plan denied your request. The Plan says the 
requested drug would be deemed a routine cost covered by the Medicare Administrative Contractor (MAC). 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Palonosetron HCL as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve Palonosetron hydrochloride HCL.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the device. You say that the enrollee will face setbacks is forced to use an 
alternate provider. The Plan denied your request. The Plan says there are in-network providers within a 
reasonable distance. 
 
The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a 
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating 
practitioner to avoid an adverse medical outcome.  
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records in this case do not document any unique features of this patient's condition 
which requires the LymphaCare device as opposed to an in-network device. The only medical visit note with a 
physical examination provided in this case (from 09/08/2022) includes conflicting information; one part of the 
exam reports "No edema," another part of the exam reports "severe edema." Nothing in the 09/08/2022 notes 
indicates medical necessity of the LymphaCare device over any other model. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the denial 
because the requested device is necessary for the enrollee's plan of care. The Plan denied your request. The 
Plan says a device that provides intermittent limb compression for the purpose of prevention of venous 
thromboembolism is a preventative service. Items that are used for a preventative service or function are 
excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
April 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented with right 
face numbness, right arm numbness and difficulty speaking that had resolved earlier that same day. The records show a basic focused history and examination but do not support a comprehensive history and exam. Due to the 
patient's stable condition on evaluation, without lingering symptoms since her episode, the records also do not 
support a high level of decision making to justify the CPT 99223. 
 
We looked at this coder'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 pay for initial hospital care (procedure code 99223) rendered on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you can use this to monitoring eating and prevent 
yourself from taking insulin 3 times per day. The Plan denied your request. The Plan says you do not meet 
criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).