Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo (J9299) to be used in combination with 
Carboplatin (J9045), Pemetrexed (J9305), and Yervoy (J9228). 
 
You asked the Plan to pre-approve Opdivo to be used in combination with Carboplatin, Pemetrexed, and 
Yervoy. You say that it is medically based on the patient's medical history, he would benefit from the 
combination of drugs. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Opdivo (J9299) combined with Carboplatin (J9045), Pemetrexed (J9305), and Yervoy (J9228) as subsequent 
treatment in the setting of disease progression on prior programmed death-ligand 1 (PD-L1) therapy have not 
been demonstrated in the peer-reviewed literature. 
 
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 Opdivo to be used in combination with 
Carboplatin, Pemetrexed, and Yervoy. Our reviewer says that Opdivo to be used in combination with 
Carboplatin, Pemetrexed, and Yervoy is not medically reasonable and necessary for the enrollee. Our physician 
reviewer found the requested treatment regimen is only indicated for first line therapy. Our reviewer found that 
the requested use of Opdivo (J9299) to be used in combination with Carboplatin (J9045), Pemetrexed (J9305), 
and Yervoy (J9228) is not Food and Drug Administration (FDA) approved for the enrollees diagnosis. Our 
physician reviewer also found that its use 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo to be used in combination with Carboplatin, Pemetrexed, and Yervoy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299) to be used 
in combination with Carboplatin (J9045), Pemetrexed (J9305), and Yervoy (J9228).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Budesonide for the enrollee. 
 
You asked the Plan to pre-approve a tier exception. You say that a tier exception is necessary. The Plan denied 
your request. The Plan says that Part B covered products are not eligible for reduction to a lower co-payment. 
 
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D 
drugs.  
 
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for 
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-
approve a tier exception for Budesonide for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car lift for a power wheelchair. 
 
You asked the Plan to pre-approve the car lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says a car lift requires modification to an automobile which is not a covered benefit under the 
Medicare line of business. 
 
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 car lift for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acupuncture provided on December 3, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Acupuncture. You say that you were misinformed that prior authorization was 
required. The Plan denied your request. The Plan says the referenced phone call was for another member and 
prior authorization is required for an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Acupuncture provided on December 3, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on December 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Domiciliary services provided on December 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary capsules 
 
You asked the Plan to pre-approve Rytary. 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 covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rytary capsules
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says that the enrollee demonstrates limited capacity or need for intensive rehabilitation. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that per documentation, the enrollee has comorbidities that will need to be actively managed in an acute 
hospital stay with an interdisciplinary approach to rehabilitation care. In addition to common complications that 
happen after stroke, that require medical monitoring/management, uncontrolled hypertension is well 
documented. Per clinical documentation, the enrollee would benefit from intense therapy (3hrs per day, 5 days 
per week) in multiple disciplines (physical and occupational therapy). New functional impairment in both 
mobility and activities of daily living are well documented as well as the recommendations by treating 
therapists and clinicians in that patient would benefit from intense physical and occupation therapy at least 3hrs 
per day, 5 days per week with an interdisciplinary approach to care. Measurable functional goals of care are 
well documented by a rehabilitation physician with an expected treatment time frame. Based on the available 
documentation, the enrollee would be expected to participate and significantly benefit from an intensive 
rehabilitation program. The enrollee participated well in therapy evaluations and clear goals of care of 
documented. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you appear to be 
at your usual baseline of function. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, you received enteral nutrition and medications, and had stable vital 
signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a 
maximal to total assist level for functional mobility. You required varying assist with activities of daily living. 
There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services 
on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met. 
 
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 there is no documentation provided indicating medical necessity for admission to an 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where she 
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. Our physician reviewer also found that the 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not meet criteria for the requested service. 
 The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records show that you last received bilateral radiofrequency 
ablation services on September 15, 2021, and September 22, 2021. 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 radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Domiciliary services provided on October 23, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 genetic testing services. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Medicare rules say that the requested testing is not medically necessary because the 
enrollee is not pregnant. 
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records do not document how the testing will change clinical management of the 
patient 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve F5 genetic testing services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that these services are 
necessary. The Plan denied your request. The Plan says that this benefit has been exhausted. 
 
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 sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures and electrical stimulation provided on 
August 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedures and electrical stimulation. You say that you do not 
understand why one date of service was paid but not the other dates of services, which were all together. The 
Plan denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider. The Plan also says that they did not 
authorize any services for these providers. 
 
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 therapeutic procedures and electrical stimulation 
provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the records 
provided do not support the need for daily therapy in a skilled nursing facility setting. 
  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 services. Our reviewer says that 
admission to a SNF for inpatient skilled rehab services is not medically necessary. Our physician reviewer 
found the member does not require skilled nursing or skilled therapy services on a daily basis. She is medically 
stable and can receive further rehab services 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 85025) rendered by the out-
of-network (OON) provider on January 5, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the laboratory services (36415, 85025) rendered by the out-of-network (OON) 
provider on January 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says it is appropriate to reduce the hours from 56 per week to 40.75 per week. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
that in this case, the documentation doesnt support that you require additional home health aide services to 
provide treatment that is medically necessary. You do not require additional home health aide services to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain the members condition and/or prevent deterioration.  You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services 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 the additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours.