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

 
We decided that the Plan does not have to pre-approve Eylea. 
 
  You asked the Plan to pre-approve Eylea. You say that you have Macular degeneration and have lost sight in 
one eye. You also say that you are having trouble with the other eye and need the injections. The Plan denied 
your request. The Plan says there is no information regarding the reason for Eylea over the preferred product. 
There is no documentation that you have a history of intolerance or an adverse event to at least one preferred 
product or a substandard response to therapy. The Plan also says that there is no documentation that this is a 
prior continuation of therapy within the past 365 days. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary. Our physician reviewer found you have not tried and failed the 
required drug, Avastin. Our reviewer also found that the documentation does not support that Avastin would 
likely be less effective, and/or would likely have adverse effects for you 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
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 Fulphila. Our reviewer says that the 
requested use of Fulphila is not supported. Our physician reviewer found the patient does not have 
comorbidites that would increase her risk of neutropenic fever and the regimen of gemcitabine and abraxane 
does not put her risk of neutropenic fever above 20%. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on September 
1, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documentation of contact in the patient record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on 
September 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not reasonable and necessary. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that there is no documentation that additional skilled therapy services are required to effectively 
provide treatment in order to improve the enrollee's level of function, or to establish a maintenance program to 
maintain her level of function or prevent deterioration. The provided records do not document any acute 
decline in function which would necessitate any further skilled therapy visits beyond what has already been 
approved. There are no medical notes from the enrollees treating physician documenting a need for additional 
skilled therapy services. Further utilization of the home exercise program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy 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. You did not provide an argument for coverage. The 
Plan denied your request. The Plan says the enrollee's care can be managed at the current inpatient hospital. 
 
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 in this case the enrollee was admitted following a fall and generalized 
deconditioning.  The record indicates that the enrollee has had a prolonged hospital course and still requires 
acute care services.  The enrollee continues to receive acute care services and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that she is not currently receiving but that 
would be available at the LTACH facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these orthotic items should be covered for the 
enrollee's condition. The Plan denied your request. The Plan says these items are not covered benefits. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
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 has anemia from 
myelodysplastic syndrome without ring sideroblasts. The Food and Drug Administration (FDA) has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Reblozyl is not 
safe and effective and reasonable and medically necessary at this time. 
 
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 Reblozyl.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390), battery (E1356), other 
related supplies and accessories (E1399, A9999), and sales tax (S9999), purchased on March 17, 2021. 
 
You asked the Plan to pay for the oxygen concentrator and supplies.. You say that the items should be covered. 
The Plan denied your request. The Plan says the purchase of oxygen equipment and supplies/accessories is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors 
pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, 
contents and supplies. Payment is not made for purchases of this type of equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen concentrator and supplies. have not been met. Therefore, we decided that the Plan does 
not have to pay for the oxygen concentrator (E1390), battery (E1356), other related supplies and accessories 
(E1399, A9999), and sales tax (S9999), purchased on March 17, 2021.
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 will need physical therapy and cannot use your 
right arm or leg.  You said that have you have in the intensive care unit for three weeks and will need rehab. 
The Plan denied your request. The Plan says IRF care is not medically necessary, and you can be managed at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care.  Our reviewer says that the requested IRF care is found to be medically reasonable and necessary for this 
enrollee. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for myocardial infarction, coronary artery bypass grafting, and cardiac arrest. Your medical problems 
are stable, and you have no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. 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 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 the patient would benefit from inpatient 
rehabilitation. The Plan denied your request. The Plan says the patient can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and spinal compression fractures. The patient's medical problems are stable and they 
have no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has 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 this patient 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 inpatient admission for shoulder arthroplasty surgery. 
 
You asked the Plan to pre-approve the inpatient admission. You did not provide a specific argument for 
inpatient admission. The Plan denied your request. The Plan says it has approved the requested surgery, but 
inpatient admission is not medically necessary.  The Plan says that the procedure care be performed on an 
ambulatory/observation basis. 
 
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 inpatient admission. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure could be performed safely in an observation stay. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient admission for shoulder arthroplasty surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that you are in the hospital, and you need to be moved to the 
IRF to regain your strength before returning home. The Plan denied your request. The Plan says the criteria for 
admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided in a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the infectious disease (viral respiratory tract infection), pathogen-
specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, 
influenza B) testing (0240U) provided on September 3, 2021. 
 
You asked the Plan to pay for the infectious disease panel. You say that you would like reconsideration because 
this testing is medically necessary and covered by Medicare. The Plan denied your request. The Plan says that 
Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has denied this service based on the rules regarding panels 
of 6 or more targets. The service at issue in this case includes 3 targets. Per the LCD, this service may be 
covered. The Plan has not forwarded any additional rationale to indicate why this service is not payable. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not 
been substantiated so we must find in your favor Therefore, we decided that the Plan has to pay for the 
infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory 
syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B) testing (0240U) provided on September 3, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder relief wedge pillow and body pillow. 
 
You asked the Plan to pre-approve a shoulder relief wedge pillow and body pillow. You say that this is 
medically reasonable and necessary. The Plan denied your request. The Plan says these items are not covered 
by Medicare or the Plan. 
 
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 shoulder relief wedge pillow and body pillow.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tomographic myocardial perfusion imaging (78452) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve tomographic myocardial perfusion imaging. You say that the service at 
issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
out-of-network services have not been met. 
 
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 
tomographic myocardial perfusion imaging (78452) to be provided by an out-of-network (OON) provider.