Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a long handle shower head. 
 
You asked the Plan to pre-approve the item. You say that you are not strong enough and need this approved. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a long handle shower head.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine gynecological exam provided on November 18, 
2021. 
 
You asked the Plan to pay for the routine gynecological exam. You say that you have not gotten a yearly 
checkup. You say that it is ridiculous this Plan only allows a yearly checkup every 2 years. The Plan denied 
your request. The Plan says a vaginal cancer screening is only covered once every 24 months. 
 
The Plan must follow Medicare rules. Medicare rules say that if the beneficiary does not qualify for an annual 
screening pelvic exam, screening pelvic exams are only paid after at least 23 months have passed following the 
month during which the beneficiary received her last covered screening pelvic exam.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine gynecological exam have not been met. Specifically, it has been less than 24 months 
since your last routine exam. Therefore, we decided that the Plan does not have to pay for the routine 
gynecological exam provided on November 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtracal Plus. 
 
You asked the Plan to pre-approve Xtracal Plus. You say that the items are necessary. The Plan denied your 
request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Xtracal Plus.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested monitor is 
medically necessary. The Plan denied your request. The Plan says the requested monitor does not meet criteria. 
 
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 an implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while you have a history of atrial fibrillation and flutter, there is no 
documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent 
indication for an ILR. In summary, there is insufficient documentation to support the medical necessity for 
insertion of an ILR in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (ILR) (33285).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Velcade (Bortezomib) (CPT code J9041), Darzalex 
Faspro (daratumumab and hyaluronidase human-fihj) (CPT code J9144), and dexamethasone (CPT code 
J1100). 
 
You asked the Plan to pre-approve the medications. You say that the medications are necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirement for coverage of the request for 
Velcade, Darzalex Faspro, and dexamethasone. The Plan states the requirement is: The enrollee has received at 
least one prior therapy for treatment of their health problem. 
 
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 the medications. Our physician 
reviewer found the requested use of Velcade (Bortezomib) and Darzalex Faspro is not FDA-approved for the 
enrollees diagnosis in this combination. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-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 the medications have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Velcade (Bortezomib) (CPT code J9041), Darzalex Faspro (daratumumab and 
hyaluronidase human-fihj) (CPT code J9144), and dexamethasone (CPT code J1100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for PCDs 
have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the available medical record does not show that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan 
does not have to pre-approve pneumatic compression devices (E0652, E0667).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the vision care services (92083, 92133, 99204, 
76514, 92020) provided on February 11, 2022, to $50. We decided that the Plan does not have to fully waive 
the copayment for these services. 
 
You asked the Plan to waive the copayment for the medical vision care. You say that you are being charged for 
services which should be fully covered by your insurance, as you were told you had no deductible with this 
plan, and this was a diabetic eye exam and glaucoma screening. The Plan denied your request. The Plan says 
that this claim was processed correctly, and your copayment was assessed in accordance with your contract. 
You are responsible for a $95 copayment for diagnostic tests performed by a provider other than your primary 
care physician. 
 
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 enrollees must pay a $50 copayment for services for the diagnosis and 
treatment of diseases and injuries of the eye.  
 
The Plan says you must pay a $95 copayment for the medical vision care. Based on the Plan contract, however, 
you cannot be asked to pay more than a $50 copayment for medical vision care. The services at issue are not 
considered either a diabetic retinopathy screening or a glaucoma screening and were not billed as such. A 
screening is provided to an enrollee who has never had a history of or shown symptoms of a condition; if an 
enrollee has a medical history of a condition or is showing symptoms, the services are considered diagnostic. 
While these are diagnostic services and were performed by a provider other than your primary care physician, 
they are more accurately described as services for the diagnosis and treatment of diseases and injuries of the 
eye. Therefore, we decided that the Plan has to reduce the copayment for the vision care services (92083, 
92133, 99204, 76514, 92020) provided on February 11, 2022, to $50.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (CPT code J7323). 
 
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 does not have any stated contraindications to the preferred products, 
the enrollee has not tried any of the preferred agents and 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 Plan requires a trial of drug Orthovisc, Synvisc or Synvisc One before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plans required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
 
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 Euflexxa (CPT code J7323).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after June 29, 2022. 
 
You asked the Plan to pre-approve SNF care after June 29, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued 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 after June 29, 2022. Our 
reviewer says that you do not meet the Medicare criteria for continued SNF care. Our physician reviewer found 
continued 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 after June 29, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 9, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care in-network except for emergency care or urgently needed 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 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional routine transports. 
 
You asked the Plan to approve these services. You say that the enrollee needs transportation to radiation 
therapy. The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
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 one-way 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 approve additional routine transports.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for medical management of low back pain associated with lumbar spinal stenosis. She is medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. 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: 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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for right lower extremity ischemia. He is now medically stable with no complex nursing or 
rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemcitabine Hcl. 
 
You asked the Plan to pre-approve Gemcitabine Hcl. 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 a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Gemcitabine Hcl. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, the record indicates 
that the enrollee has a diagnosis of metastatic squamous cell carcinoma of the penis. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine Hcl have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Gemcitabine Hcl.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after July 3, 2022. 
 
You asked the Plan to pre-approve SNF care after July 3, 2022. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says that the continued 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 after July 3, 2022. Our 
reviewer says that you meet the Medicare criteria for continued SNF care. Our physician reviewer found there 
is documentation that you required the services on an inpatient basis in a skilled nursing facility setting. As a 
practical matter records document that outpatient intravenous infusion services could not be set up on a holiday 
weekend (despite documented attempts to do so) and continued services in the skilled nursing facility appear to 
be 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 SNF care after July 3, 2022, 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 continued skilled nursing facility (SNF) care after July 3, 2022.  
 
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.