Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested 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 appear to be currently still unstable and requires short-term additional acute care 
services that can safely be completed at the current facility until more stable. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. Transfer may be 
considered when treatment has completed and you are more 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pertuzumab (J9306) and Kanjinti (Q5117). 
 
You asked the Plan to pre-approve Pertuzumab and Kanjinti. You say that the enrollee had progression of 
cancer on first line multiagent chemotherapy. You also say that the enrollee had side effects from the 
chemotherapy resulting in a decrease in performance status. The Plan denied your request. The Plan says the 
requested regimen is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Pertuzumab and Kanjinti. Our reviewer 
says that the requested drugs, Pertuzumab and Kanjinti, are not medically necessary. Our physician reviewer 
found the requested drugs are not approved by the Food and Drug Administration (FDA) for the enrollee's 
diagnosis. The reviewer found that the use is not supported by any of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). 
Therefore, the reviewer found that the requested drugs are not 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 Pertuzumab and Kanjinti have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Pertuzumab (J9306) and Kanjinti (Q5117).
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 IRF is medically necessary because you are trying to 
stay in her own home but that can only be done if you can transfer mobility and this is why this is needed. The 
Plan denied your request. The Plan says IRF is not medically necessary, and you can be managed at a lower 
level of care. 
 
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 do not need physician close supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. You have no rehab nursing needs identified or documented in the record. 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 will not make a significant functional recovery in the predicted 7-10 
days in an IRF. IRF admission is not medically necessary based on medical stability and lack of medical 
complexity, and lack of rehab nursing needs. While you may benefit from therapies, your rehab rehab can be 
safely provided at a lower intensity and alternate 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need to have surgery done by the same 
surgeon. The Plan denied your request. The Plan says your needs can be met in-network. 
 
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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested device. You say that alternative modes of ventilation therapy 
have been tried and failed. The Plan denied your request. The Plan says a setting that could be delivered by 
BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 device. Our physician 
reviewer found that in this case, the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The settings ordered are AVAPS-AE. The record indicates that the enrollee improved in the hospital 
on BiPAP. The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability.  The plan has indicated such a device is available. Therefore, the requested device is not 
medically reasonable or 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. You say that you are having trouble going on outings. The 
Plan denied your request. The Plan says you have not completed the necessary evaluations. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power scooter. Your current device serves the same purpose as the requested 
wheelchair. The wheelchair is also for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-area 
provider. 
 
You asked the Plan to pre-approve out-of-area services. You say that you cannot live alone with the treatment 
needed. The Plan denied your request. The Plan says your health care needs can be rendered in-network. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
 
 We looked at the file, and Medicare rules. The requested services are available from an in-network provider. 
The need for services is known prior to leaving the service area. We found no exception which would require 
the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-
approve oncology services to be provided by an out-of-area provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says there is 
no evidence that the enrollee needs a new device. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and the rules. The records show that the device is needed to replace an old device. The 
enrollees current device serves the same purpose as the requested device. There are no records to indicate the 
current device has irreparable damage or is at least 5 years old.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the in-network provider does not have a 
Chinese-speaking person. The Plan denied your request. The Plan says you do not meet the standards for out-
of-network care. 
 
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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve pain 
management services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adjacent tissue transfer, wound excision, and graft to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the adjacent tissue transfer, wound excision, and graft. You say that the 
member has a large open wound on her face making her susceptible to infection. You say that it is medically 
necessary to close the wound tomorrow morning to avoid any possible infection. The Plan denied your request. 
The Plan says in-network providers are available. 
 
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 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 adjacent tissue transfer, wound excision, and graft to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says a setting 
that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 device. Our physician 
reviewer found that in this case, you have chronic obstructive pulmonary disease and a history of recent Covid-
19 infection with a normal arterial blood gas. The order indicates that the settings include AVAPS-AE. The 
provided primary source documentation does not contain sufficient detailed information to justify the treatment 
selected. You can be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a 
device is available. Therefore, the requested ventilator is not 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
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 IRF would maximize the enrollee's return to prior 
level of function. The Plan denied your request. The Plan says the denial of authorization for IRF care is 
correct. 
 
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 is medically stable and does not need rehabilitation physician close supervision 3 times per week for ongoing management. While the enrollee may benefit from physical and 
occupational therapy, the enrollee's rehabilitation needs can be safely provided in a lower intensity alternate 
setting such as skilled nursing facility 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that you are appealing the decision 
for the Vertiflex procedure based on your BMI. You say that you would like an approval for the procedure 
now. The Plan denied your request. The Plan says interlaminar and interspinous process decompression 
systems are considered investigational for all indications. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that interspinous process devices remain experimental and more research is 
needed.  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
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 updated notes and documentation 
support an LTACH placement. The Plan denied your request. The Plan says the enrollees medical needs are 
being met in the current acute setting. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 Genetic Testing. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 Genetic Testing. You say that the requested genetic 
testing is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested BRCA1 and BRCA2 genetic testing. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA1 and BRCA2 Genetic Testing, is being requested solely for screening 
purposes as the documentation does not support that you have had a personal history of breast, ovarian, fallopian 
tube, primary peritoneal, pancreatic, or prostate cancer. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 Genetic 
Testing.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 
 
You asked the Plan to pre-approve Eliquis. You say that the patient is non-therapeutic on Warfarin and has 
bleeding with Xarelto and Pradaxa. The Plan denied your request. The Plan says this drug is not covered under 
the patient's medical benefits. 
 
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 Eliquis  
 
Benefits for Eliquis 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92014) provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you would like to appeal this 
copayment. The Plan denied your request. The Plan says the copayment amount that you are being charged is 
correct. 
 
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 $40 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye for Vision care.  
 
You have been asked to pay a $40 copayment for Medicare-covered exams to diagnose and treat diseases of the 
eye for the eye exam. The eye exam falls within the Vision care 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 the eye exam (92014) provided on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar surgery services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested procedure is not indicated at this level. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that lumbar laminectomy services were requested. The Plan has agreed to pre-approve services 
at L4-5. 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 services at L5-S1. 
Our physician reviewer found that the imaging studies do not show severe spinal stenosis at L5-S1. Therefore, 
surgery is not needed at this level. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar surgery services.