Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on July 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that this was an urgent care visit and should not require 
a referral. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist visit provided on July 12, 2022, by an 
out-of-network (OON) 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 enrollee requires prolonged and 
intensive skilled services that are not available in a lower level of care. You say that the enrollee's needs 
aggressive physical therapy and occupational therapy to regain maximum function to ensure a safe and 
sustainable discharge. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met at a lower level of care. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve Opzelura. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says this is a self-administered drug. 
 
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 Opzelura.   
Benefits for Opzelura 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (CPT code J3111). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried any of the preferred agents. The Plan states the provider 
does not provide a rationale for use of the non-preferred product for safety or efficacy. 
 
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 the medication. Our physician reviewer 
found the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. 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 alternative. 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. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity (CPT code J3111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuromuscular electrical stimulation (NMES). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NMES is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have multiple 
sclerosis and right foot drop with gait abnormality. There is no documentation that you meet the criteria for use 
of the NMES. There is no documentation of a spinal cord injury or muscle breakdown due to lack of use 
(disuse atrophy). The NMES is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve neuromuscular electrical stimulation (NMES).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gralise 300mg tablets. 
 
You asked the Plan to pre-approve Gralise. You say that Gralise is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical 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 pre-approve Gralise 300mg tablets.  
 
Benefits for Gralise 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensor. You say that the Freestyle Libre 3 is the only 
product that you've tried that helped you control your blood sugar, and you cannot understand why a product 
would come out and not be covered under Medicare. The Plan denied your request. The Plan says the Freestyle 
Libre 3 sensor does not meet the definition of a Part B product. This drug is excluded from coverage. 
 
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. This version of the FreeStyle Libre is not eligible for coverage under 
Medicare. At this time, the FreeStyle Libre 3 is not currently eligible for Medicare reimbursement. The 
Freestyle Libre 2 is a Medicare covered benefit. Based on this information, we decided that Medicare rules for 
coverage of the Freestyle Libre 3 sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Freestyle Libre 3 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 10, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 10, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve Vascepa. You say that this drug should be covered. The Plan denied your 
request. The Plan says this is a self-administered drug. 
 
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 Vascepa.  
 Benefits for Vascepa 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in average volume-
assured pressure support (AVAPS) mode with Auto-expiratory positive airway pressure (EPAP) (AE) that 
could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the Plans contracted delegate was provided the records for this 
DME and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, 
we decided that the Plan has to pre-approve the home ventilator (CPT code E0466).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain medicine visit provided on August 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a pain medicine visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a pain medicine visit provided on August 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for mycophenolate mofetil. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only eligible for Part D drugs. 
 
We looked at the file and Medicare rules. The requested drug is covered under Part B Medicare and is not 
eligible for a Part D tier exception. Based on this information, we decided that Medicare rules for coverage of 
these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier 
exception for mycophenolate mofetil.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain due to 
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Synvisc is not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc.
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. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
October 4, 2021. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged 
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 $100 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $100 copayment for a computerized tomography (CT) scan. This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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. Therefore, we decided that the Plan 
does not have to waive the copayment for a computerized tomography (CT) scan on October 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dialysis services on July 1, 2022, to July 
31, 2022. 
 
You asked the Plan to waive the copayment for dialysis services. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged 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 dialysis services.  
 
You have been asked to pay a 20% coinsurance for dialysis services. This item/service falls within the Services 
to treat kidney disease 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. Therefore, we decided that the Plan does not have to waive the copayment for dialysis 
services on July 1, 2022, to July 31, 2022.
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 enrollee needs to return to the SNF in order to 
receive therapy. It is not possible to have her leave the home for therapy, and it is not safe to do so. The Plan 
denied your request. The Plan says SNF admission is not medically necessary. The enrollee's needs can be met 
at home with supervision and home health 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided, there is no documentation that the patient 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex 
wound care or respiratory care. While the patient does have skilled therapy needs, there is no documentation 
that daily skilled services are required. Although records document the patient is very limited functionally, the 
provided records do not document a significant decline in the patients functional status compared to her recent 
baseline to necessitate daily inpatient skilled therapy services. Based on the medical records provided there is 
no documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Records do not support that services in the home or an assisted living facility with home health care or 
in a long-term care facility on a part-time basis are not appropriate in this case. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment of methadone (G2067) and a 
take home supply of methadone (G2078) provided on April 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment of methadone (G2067) and a take home supply of 
methadone (G2078). You say that that this facility is an opioid treatment program (OTP) clinic. You also say 
that no authorization is required for federally qualified health centers (FQHC) tribal OTP facilities due to the 
patient's not making appointments, but coming in when they decide to seek treatment, per the Centers for 
Medicare and Medicaid Services (CMS). The Plan denied your request. The Plan says the member does not 
have out of network benefits. The Plan also says that the referring provider is a non-contracted provider, as 
well as no indication any attempt was made to obtain prior authorization for the out of network services. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for medication assisted treatment of methadone 
(G2067) and a take home supply of methadone (G2078) provided on April 18, 2022, by an out-of-network 
(OON) provider.