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

We decided that the Plan does not have to pre-approve Libtayo (J9119).
You asked the Plan to pre-approve Libtayo. You say that this drug is necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug/regimen is not being prescribed for a supported medically accepted indication.
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 Libtayo. Our reviewer says that this requested drug is not medically reasonable and necessary. Our physician reviewer found the requested use of Libtayo is not FDA-approved for the enrollee's diagnosis. In this case, FDA-approval is for first-line treatment of non-small cell lung cancer in patients whose tumors have high PD-L1 expression (Tumor Proportion Score =50%) as determined by an approved test, with no estimated glomerular filtration rate (EGFR), anaplastic lymphoma kinase (ALK), or ROS1 aberrations, and locally advanced (in patients who are not candidates for surgical resection or definitive chemoradiation) or metastatic disease. This would be 2nd line and the patient is
EGFR positive. Furthermore, the use of the requested drug is not supported by one of the major drug
compendia or by clinical research that appears in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to
pre-approve Libtayo (J9119).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the medical records provided support the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met at an alternate level of 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus shot provided on May 4, 2021.
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that you were told this
vaccine would be covered. The Plan denied your request. The Plan says preventative tetanus shots are covered
under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under
Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or
directly exposed to any illness related to vaccines under Medicare Part B. Therefore, we decided that the Plan
does not have to pay for a tetanus shot provided on May 4, 2021. Benefits for preventative vaccines under
Medicare Part B may be available under Medicare Part D. Contact the Plan that administers Part D benefits for
further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from May 2, 2021,
through May 31, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services 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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications and a course of Intravenous antibiotics. The enrollee had
stable vital signs. He had uncomplicated wound care to his right lower extremity. He had a dental consult for a
chipped tooth. Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy. There
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The
enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee
does not meet severity of illness or intensity of service criteria for 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 continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from May 2, 2021, through May 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related
group (DRG) code 871 provided from January 27, 2020, to February 6, 2020.
You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that the assessment
and diagnosis of sepsis for this patient fulfilled the definition of sepsis per the Sepsis-3 guidance. The Plan
denied your request. The Plan says DRG 871 is not supported as the diagnosis of sepsis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis,
unspecified organism. 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 pay for the inpatient hospital
services billed with DRG 871. Our reviewer says that DRG 871 is not supported. Our physician reviewer found
while the enrollee's presentation warranted consideration of sepsis as possible diagnoses, there was no evidence
of meeting the Sequential Organ Failure Assessment (SOFA) score of 2 or more points that cannot be easily
explained by causes other than sepsis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services billed with diagnosis related group (DRG) code 871 provided from January
27, 2020, to February 6, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve Prednisone. You say that the enrollee has been taking this medication for
several years. The Plan denied your request. The Plan says Prednisone to be administered at home is not
covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diagnostic colonoscopy (CPT code 45378) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve the diagnostic colonoscopy. You say that you are requesting review of
denial of services. The Plan denied your request. The Plan says the provider you requested is not part of your
primary care physician's network. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plan says that the Plan must 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 the diagnostic colonoscopy (CPT code 45378) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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. Our
physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require that are not available at the health care setting being offered
by the health plan.
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided at the in-network
benefit level by an OON provider.
You asked the Plan to pre-approve physical therapy. You say that the enrollee needs physical therapy to better
care for her spouse. The Plan denied your request. The Plan says the denial of authorization at the in-network
benefit level is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by
an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that enrollees may choose to receive care from either an in-network or out-of-network provider.
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 at the in-network benefit level. The enrollee may receive care from
this provider at the out-of-network benefit level, please contact the Plan for more information about the
enrollee's out-of-network benefits. Therefore, we decided that the Plan does not have to pre-approve physical
therapy to be provided at the in-network benefit level by an OON provider.
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 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 daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can
be provided 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 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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: 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 does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2784, V2200, V2020) provided on June 25, 2021.
You asked the Plan to pay for the eyeglasses. You say that these services were necessary, and your previous glasses were old and needed replaced. The Plan denied your request. The Plan says you previously received a pair of eyeglasses in May 2020, which were covered by the Plan at this time. Your benefit only covers one pair of eyewear every two years. Therefore, your benefit was exhausted on the date in question and payment will not be made.
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 once every two years. We looked at the file and the Plan's rules. Documentation shows that you previously received a pair of routine eyeglasses less than two years before the date in question, which were paid for by the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2784, V2200, V2020) provided on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection rendered on
October 27, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you were previously not charged
for the injection. The Plan denied your request. The Plan says the coinsurance was applied correctly.
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 20%
coinsurance for each Medicare-covered Part B drug.
Review of the file shows that you received a denosumab injection on October 27, 2020. You have been asked
to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug
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
Plan confirmed that you have been assessed a 20% coinsurance for these services for past dates of service.
Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection
rendered on October 27, 2020
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 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 daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's care needs, as a
practical matter, can be provided 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 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 deductible for the office visit rendered on May 27, 2021.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 yearly deductible which applies to your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the services obtained from a primary care provider benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible which applies to your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on May 27, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit rendered on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the
enrollee's upper limb strength and function are adequate for the enrollee to control the power options using
their own switches.
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 requested items. Our physician
reviewer found that the enrollee has a past medical history of a stroke who requires a power wheelchair for
mobility. The enrollee is independent with dressing, feeding and personal hygiene, thus indicating his upper
extremity strength and function are adequate to control the power options using their own switches. There is no
documentation that the requested expandable control system meets Medicare criteria for being medically
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 the requested items have not been met. Therefore, we decided that the Plan does
not have to pre-approve an expandable control system.