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

 
We decided that the Plan does not have to pay for self-administered drugs received on October 18, 2021. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for self-administered drugs received 
on October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 29, 2021. 
 
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 this code has a bundled relationship with another code. 
 
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux (J9055). 
 
You asked the Plan to pre-approve Erbitux. You say that the drug is medically necessary. The Plan denied your 
request. The Plan says the drug 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 Erbitux. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the requested drug is not FDA_approved for 
the enrollee's diagnosis and there is no support in any of the th major drug compendia for the use of this 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 Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux (J9055).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 you do 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You are functioning below your baseline. The documentation did not yet establish that a new, lower 
level of function had been reached. Daily skilled services were required to establish a maintenance program 
and/or to prevent deterioration of your condition. Improvement while awaiting the appeal does not justify a 
denial. You do 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fasenra (J0517) and the associated administration 
(96372). 
 
You asked the Plan to pre-approve Fasenra and the associated administration. The Plan denied your request. 
The Plan says Fasenra, being supplied by a Specialty Pharmacy and self-administered, is not eligible for 
Medicare coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Fasenra (J0517) and the 
associated administration (96372).  
  
Benefits for Fasenra and the associated administration 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 24 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 24 routine transportation trips. You say that you need 
transportation to get to your medical appointments. The Plan denied your request. The Plan says you have 
utilized the maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 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 an additional 24 routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuedexta. 
 
You asked the Plan to pre-approve Nuedexta. You say that you would like Nuedexta to be approved for the 
enrollee so that he can continue to have excellent symptomatic relief of pseudobulbar symptoms. The Plan 
denied your request. The Plan says Nuedexta is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Nuedexta.  
 
Benefits for Nuedexta 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: Favorable

 
We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 the SNF admission. Our reviewer says 
that you do meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a 
skilled professional therapist. You are reported to be functioning below your baseline. The provided 
documentation does not yet establish that a new, lower, level of function has been reached. Daily skilled 
services are required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, as a practical matter, cannot be provided at a lower level of care. You do 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 the SNF admission have not been met. Therefore, we decided that the Plan has 
to pre-approve admission to a skilled nursing facility (SNF).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found 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 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant services (99509). 
 
You asked the Plan to pre-approve the attendant services. You say that you would like custodial care to be 
covered for this enrollee so she can receive the care she needs to avoid a permanent bedridden status. You also 
say that without daily custodial care she will not be able to get out of bed on her own. The Plan denied your 
request. The Plan says Medicare criteria for home health care do not cover this type of care for any reason. The 
Plan also says that neither Medicare nor the enrollee's health plan covers this care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the attendant services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant 
services (99509).
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 cannot be alone and require intravenous 
medications and intensive physical therapy. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 are medically stable and does not need physician supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. Our reviewer found that you do not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. You need 
routine physical therapy and occupational therapy, but your therapy needs can be addressed in a skilled nursing 
facility. Our physician reviewer also found that an IRF admission is not medically necessary based on lack of 
medical complexity and lack of acute rehabilitation nursing needs. 
 
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 enrollee requires the level of care 
provided at the LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH 
service is correct. 
 
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 the enrollee appears to be improving gradually but is still unstable and requires 
additional short-term acute care services that can be safely administered at the current facility. The enrollee 
does not require services at the LTACH that are not available and covered at the current facility. Transfer to 
LTACH would not be clinically advantageous as the enrollee is not yet stable. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autogenous connective tissue graft procedure (D4273 
x6). 
 
You asked the Plan to pre-approve autogenous connective tissue graft procedure. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the service at issue is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
autogenous connective tissue graft procedure (D4273 x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that Aduhelm is not investigational and has been granted 
approval. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because Aduhelm 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 Aduhelm. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Aduhelm. Our physician reviewer found treatment with 
Aduhelm should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, as 
this is the population in which treatment was initiated in clinical trials. There is no safety or effectiveness data 
on initiating treatment at earlier or later stages of the disease than were studies. The requested use of Aduhelm 
is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This is not supported by one 
of the major drug compendia or by clinical research appearing 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Aduhelm.
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 SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that records do not show you need either skilled nursing or rehab care daily 
as noted. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 you are unable to walk and would be unable to care 
for yourself if discharged at this time. The Plan denied your request. The Plan says your request does not meet 
Medicare guidelines because you no longer require skilled services on a daily basis.  
 
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 that there are no identifiable skilled nursing 
service needs or skilled therapy service needs on a daily basis. You do not meet the 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.