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

 
We decided that the Plan does not have to pre-approve Ilumya for the enrollee. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or 
cause adverse effects for the member. 
 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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary. The enrollee has plaque psoriasis. The requested medication is a 
new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step 
one alternatives. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the Plan's preferred step one alternatives. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical pump, 
stationary or portable (E2402). 
 
You asked the Plan to pre-approve a negative pressure wound therapy electrical pump. You say that the 
requested device is medically necessary. The Plan denied your request. The Plan says the requested services are 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a negative pressure wound therapy 
electrical pump. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found due to lack of progress note by physician 
documenting improvement with ongoing therapy and lack of progress notes. There is no change in wound 
volume from March to July and nothing is provided from April, May and June. 
 
 
 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 negative pressure wound therapy electrical pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy electrical 
pump, stationary or portable (E2402).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol tartrate. 
 
You asked the Plan to pre-approve Arformoterol tartrate. 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. 
 
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 Arformoterol tartrate. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the record does not indicate 
that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria 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 Arformoterol tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol tartrate.
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. The Plan denied your request. The Plan says the enrollee does not 
need the assistance of a multidisciplinary team to monitor his condition and does not need to be seen face-to 
face by physiatrist three time per week. The Plan also says that based on the enrollee's current needs, they can 
be safely met in a less intensive 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. Our reviewer 
found that 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. Our physician reviewer also 
found that 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MI profile test (CPT code(s): 88381 and 81479). 
 
You asked the Plan to pre-approve the testing. You say that the service is necessary. The Plan denied your 
request. The Plan says this test has not been approved by the Food and Drug Administration (FDA- public 
health group) to be used to help guide treatment options for the enrollee's condition. 
 
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 testing. Our physician reviewer 
found front line immunotherapy is treatment for metastatic renal cancer. As there are no actionable mutations, 
there is no role for molecular testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MI profile test (CPT code(s): 88381 and 81479).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that the enrollee has been taking prednisone. You say that 
it did not work. You also say that it is not recommended for maintenance therapy for the enrollee's condition. 
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.  
 
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 Entyvio. Our reviewer says that the 
requested drug, Entyvio, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) 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 reviewer found that the elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that the trips are 
necessary. The Plan denied your request. The Plan says your benefit only allows twenty-four (24) trips for this 
service and you have used twenty-four (24) trips which exceeds your benefit limit; therefore, this request is not 
covered by your health plan. 
 
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.  
 
Your request exceeds your benefit. Your 2022 EOC says up to 24 one-way trips are covered each year (limited to ground transportation only). The 15th trip and beyond is not a covered benefit. Therefore, we decided that 
the Plan does not have to pre-approve ten (10) additional trips for routine transportation.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for SNF care and can be treated in a lower level of care 
such as in an assisted living facility with home health services or in a long-term care facility with part-time 
skilled services. 
 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 
skilled nursing facility (SNF) care is not medically necessary. Our physician reviewer found that you do not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  The 
enrollee can receive further services at a lower 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: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve a Roll-A-Bout. 
 
You asked the Plan to pre-approve a Roll-A-Bout. 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. 
 
The Plan follows Medicare rules. Medicare rules say that mobility assistive equipment 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 a Roll-A-Bout. Our reviewer says that 
the services are medically necessary. Our physician reviewer found you have documented mobility and 
activities of daily living (ADL) impairments and the provider states that roll about or forearm crutch is 
medically necessary. Therefore, the requested item meets NCD criteria. 
 
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 Roll-A-Bout have been met. Therefore, we decided that the Plan has to pre-
approve a Roll-A-Bout.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
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 that the provider documentation/recommendation states that enrollee would benefit 
from a short stay of less intensive rehabilitation in a subacute setting. Evaluating occupational therapist also recommends less intense rehabilitation in a sub acute setting thus enrollee would not be expected to tolerate in 
an intensive rehabilitation program in an IRF. Does not meet IRF criteria based on clinical documentation. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for cancer (CPT code 0037U). 
 
You asked the Plan to pre-approve the testing. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Medicare guidance says this test is 
cover for member with advance cancers. The enrollee has an early cancer. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing for cancer (CPT code 0037U).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 a 
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
  You asked the Plan to pre-approve the SNF admission. You say that you are requesting an appeal to the SNF 
due to living alone and needing assistance to move around and that you would benefit from additional physical 
therapy. The Plan denied your request. The Plan says there is no documentation to show any intense and 
complex care needs which would require skilled nursing facility level of care and this level of assistance can be 
provided at a lower and less restrictive level of care such as home health physical therapy/occupational therapy, 
support from family, home health aide, companion care, and/or custodial care. 
 
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 SNF admission. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found based on the documentation 
provided, it is their opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is not shown to have a significant decline in function. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs can, as a practical matter, be provided at a lower level of care such as home health services, assisted 
living, or long-term 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional reimbursement for eyewear purchased on 
February 25, 2022. 
 You asked the Plan to pay for the services. You say that this was the first claim for the year. The Plan denied 
your request. The Plan says there is maximum benefit of $350 for these services/ 
 
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 covers these services with up to a $350 yearly allowance. 
 
We looked at the file and the Plan's rules. You are responsible for any charges above $350. The file shows that 
$350 was already paid for this claim to the provider. Based on this information, we decided that the Plan's rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
additional reimbursement for eyewear purchased on February 25, 2022.