Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment (D0603) provided on September 1,
2021.
You asked the Plan to pay for the caries risk assessment (D0603). You say that the office didn't submit the
claim to your primary insurance first. The Plan denied your request. The Plan says the service 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 Plan's 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 pay for the caries
risk assessment (D0603) provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 8, 2021, through
June 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration
because the inpatient hospital admission was medically necessary. The Plan denied your request. The Plan says
that the member did not meet Medicare coverage criteria for the inpatient hospital admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found due to severe hypotension, signs suggestive of severe infection, and requirement of IV
antibiotics and midodrine, it was expected that the enrollee was to require hospital services that would cross 2
midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from June 8, 2021, through June 12, 2021.
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 Euflexxa.
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
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do
not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 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 Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin for the enrollee.
You asked the Plan to pre-approve the drug. You say that due to the high copayment, Mvasi (the approved
drug) is unaffordable to the enrollee. The Plan denied your request. The Plan says Mvasi has been approved.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical
records, the enrollee has not tried and failed the required drug - Mvasi. There is no indication that Mvasi would
likely be less effective and/or likely to 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Avastin for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on
June 29, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the claims records found reveal benefits
have been paid for the round trip transport.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be an exact duplicate are rejected and do not have appeal rights.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance services have not been met. Specifically, the record indicates that the transportation
services were previously processed and paid for the billed date of service. The documentation submitted does
not support that additional transportation was rendered on the billed date of service. Therefore, we decided that
the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone transdermal solution.
You asked the Plan to pre-approve testosterone transdermal solution. You say that the enrollee has been using
this transdermal solution since 2018 with success. The Plan denied your request. The Plan says the requested
drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part
D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 testosterone transdermal
solution.
Benefits for testosterone transdermal solution 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 a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you had a stroke, and this will help keep your
balance so you do not fall. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is not covered under the medical plan.
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 Otezla for the enrollee.
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 this is medically necessary. The Plan denied your
request. The Plan says an intensive rehabilitation program is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided 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. The enrollee does require physical and occupational therapy services, but does
not require an intensive rehabilitation program. Care in the home with home health services appears to be
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 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 Tecentriq, Carboplatin, and Etoposide
You asked the Plan to pre-approve Tecentriq, Carboplatin, and Etoposide. You say that you would like
reconsideration because this drug regimen is medically necessary. The Plan denied your request. The Plan says
the requested drugs are not medically reasonable and necessary.
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 Tecentriq, Carboplatin, and Etoposide.
Our reviewer says that this drug regimen is not FDA approved for the member's condition. Our physician
reviewer found the use of this drug regimen is not supported by one of the major drug compendia or by clinical
research that appears in CMS-approved medical journals.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq, Carboplatin, and Etoposide have not been met. Therefore, we
decided that the Plan does not have to pre-approve Tecentriq, Carboplatin, and Etoposide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271) to be used in conjunction with Alimta.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee does not
meet the criteria for coverage.
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 Keytruda. Our reviewer says that
Keytruda (J9271) to be used in conjunction with Alimta is not medically reasonable and necessary for the
enrollee. Our physician reviewer found the requested use of Keytruda is not Food and Drug Administration
approved for the enrollee's diagnosis as combination therapy in patients with progression on epidermal growth
factor receptor (EGFR) related therapy. Our reviewer found that the use of Keytruda is not supported by one of
the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services
approved medical journal. Our physician reviewer also found that the use is not listed as not indicated, not
supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda (J9271) to be used in conjunction with Alimta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy (J9228) and Opdivo (J9299)
You asked the Plan to pre-approve the Yervoy and Opdivo. You say that you would like reconsideration because the requested drugs
are medically necessary. The Plan denied your request. The Plan says Yervoy and Opdvio are not medically reasonable and necessary
for the enrollee's condition.
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 Yervoy and Opdivo. Our reviewer says that the requested use of Opdivo and Yervoy
is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found 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 Yervoy and Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy
(J9228) and Opdivo (J9299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no medical complexity that requires close supervision by a rehabilitation
physician or nurse.
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. The enrollee
was admitted for surgical repair of an ankle fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee 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. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy visits provided from July 7, 2021, to August
2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy visits. You say that you were told that if you got a referral there
was a chance you would be reimbursed. The Plan denied your request. The Plan says the denial of payment for
these services is correct, because there is no evidence that seeing a provider within the Plan network would
have been detrimental to your health or that you needed to see a provider outside of the Plan 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 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 psychotherapy visits provided from July 7, 2021,
to August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says a subcutaneous injection that can be self-administered is covered by the pharmacy/drug
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 Ozempic for the enrollee.
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 admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be safely received in a different setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Services in the home with home health care as needed appear 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 the 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee is stated to have mild
cognitive impairment. She has chronic memory loss and other amnesia. Magnetic resonance imaging (MRI) on
October 10, 2021 showed moderate old small vessel ischemic changes with some progression since 2018 and
2019. The documentation is insufficient to support that Aduhelm is medically reasonable and necessary for the
enrollee. The FDA-approved label states that Aduhelm is approved under accelerated approval based on
reduction in amyloid beta plaques observed in patients treated with Aduhelm. The enrollee's case file does not
contain documentation of amyloid beta plaques. The MRI imaging in this case suggests the presence of
cerebrovascular disease, which is evidence of a mixed cause for the enrollee's symptoms. Aduhelm 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 Aduhelm.