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 IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says medical necessity rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that you 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 incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are paralyzed, and wheelchair 
bound. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of GenVisc. 
 
You asked the Plan to pre-approve GenVisc. You say that the enrollee prefers GenVisc because it is more 
financially feasible. The Plan denied your request. The Plan says the denial of authorization for this drug is 
correct, because the Plan requires a trial of Orthovisc, Synvisc, or Synvisc-One before it will approve GenVisc. 
 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 GenVisc. Our reviewer says that the 
enrollee does not meet the criteria for a step therapy exception for GenVisc. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One. The record 
does not show that these drugs would likely be less effective and/or 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 GenVisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of GenVisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says there is no evidence that you need an intensive team for your care, or that 
you are expected to improve a lot in a reasonable amount of time. 
 
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 that while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program that an IRF would provide. 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 Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not being prescribed for a medically 
accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Erbitux. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of invasive colon cancer that is of cecal origin and therefore from the 
right sided colon. 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 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 Erbitux have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Erbitux.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
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 step therapy guidelines were not followed. 
 
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 the Plan requires a trial 
of Forteo before they will approve the requested drug. In this case, the patient has niot tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee has tried other medications with no 
results. The Plan denied your request. The Plan says the enrollee has not tried the preferred drug, Forteo. 
 
 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 Evenity. Our physician reviewer found 
that the enrollee has age-related osteoporosis without current pathological fracture. The Plan requires a trial of 
Forteo before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plans required drug would likely be less 
effective or likely have adverse effects for this 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at 
a lower level of care such as at a skilled nursing facility, on an intermittent basis at home with home health 
care, or in a long-term care setting. 
 
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 that although documentation supports the need for skilled therapy there is no 
evidence that intense or interdisciplinary rehabilitation is required. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anti-reflective coating for lenses. 
 
You asked the Plan to pre-approve anti-reflective coating. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pre-approve anti-reflective coating for lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you need to see this doctor 2 times a 
year at this facility. You also say you wear a prosthesis in your left eye that the doctor has to clean every 6 
months, because if it is not cleaned it gives you itching and a lot of discomfort. You also say that the doctor 
polishes it and pours a liquid on it. The Plan denied your request. The Plan says there are participating 
providers 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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the ophthalmological medical examination 
and evaluation (92014) rendered by the out-of-network (OON) provider on August 5, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to issue reimbursement for the ophthalmological medical examination and evaluation (92014) 
rendered by the out-of-network (OON) provider on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 low air loss mattress (E0277). 
 
You asked the Plan to pre-approve a group 2 low air loss mattress. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the three Criteria listed 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 a group 2 low air loss mattress. Our 
reviewer says that the member does not need this item. Our physician reviewer found there is no 
documentation of any rashes or skin ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 low air loss mattress have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group 2 low air loss mattress (E0277).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that without SNF level of care, the enrollee's health, 
well-being and quality of life will decline and her life will be at a critical state. The Plan denied your request. 
The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirements for 
approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CXbladder genomic urine testing (88120). 
 
You asked the Plan to pre-approve the CXbladder test. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this is not considered the 
standard of care or medically necessary as it is unclear if urinary biomarkers offer valuable or useful 
information in detection and management of bladder cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CXbladder test have not been met. Therefore, we decided that the Plan does not have to pre-
approve CXbladder genomic urine testing (88120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eye Prosthesis to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Eye Prosthesis. You say that the doctor will do that procedure and the 
member needs to it to get approved. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services can be received 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 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 
Eye Prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and diagnostic nasal endoscopy to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the plan provided specialists are not 
appropriate for the service that you are requesting. You say that the facility you are being referred to by your 
doctor clearly provides the appropriate service that you are looking to receive. The Plan denied your request. 
The Plan says there are in network providers 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 
an office visit and diagnostic nasal endoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An Office Visit provided on January 24, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for An Office Visit. 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 it was determined 
these services were not urgent or emergent. 
 
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 An Office Visit provided on January 24, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic tests provided on February 10, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the diagnostic tests. You say that even though no prior authorization was 
obtained it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the diagnostic tests provided on February 10, 
2021, by an OON provider.