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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the records do not indicate that the enrollee meets the diagnostic criteria for 
both Alzheimer's Disease and frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan may be medically reasonable and 
necessary for patients who meet diagnostic criteria for both Alzheimers Disease (AD) and frontotemporal 
dementia (FTD). 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet criteria for the requested PET scan. Our physician reviewer found the enrollee is 
suspected of having either a reversible cause of dementia (such as low B12), autoimmune encephalitis, or 
Alzheimer's Disease (AD). There was no indication or suspicion of frontotemporal dementia (FTD) noted, nor 
does the enrollee meet diagnostic criteria for both AD and FTD. As such, this scan would not be 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 PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan provided on August 5, 2022. 
 
You asked the Plan to pay for CT scan. You say that this should be covered. The Plan denied your request. The 
Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for CT scan provided on August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network dermatological treatment 
provided on May 09, 2022, to May 17, 2022. 
 
You asked the Plan to reduce the copayment for an in-network dermatological treatment. You say that you 
should only have one $45 copayment. Not three. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for specialist under certain circumstances. 
 
You have been asked to pay a $90 copayment for an in-network dermatological treatment. This item/service 
falls within the specialist under certain circumstances benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. There is a $45 copayment for each specialist under certain 
circumstances. Each visit is a different billing, therefore, there is a copayment due each time ($45 copayment x 3 visits = $90 total). Therefore, we decided that the Plan does not have to reduce the copayment for an in-
network dermatological treatment provided on May 09, 2022, to May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve hypoglossal nerve stimulation.  
You asked the Plan to pre-approve hypoglossal nerve stimulation. You say that you need this for your life-
threatening condition. The Plan denied your request. The Plan says that your body-mass index (BMI) is over 
35. 
 
The Plan follows Medicare rules. Medicare rules state that hypoglossal nerve stimulation is only covered under 
certain circumstances. 
 
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 hypoglossal nerve stimulation. Our 
reviewer says that you meet criteria for this procedure. Our physician reviewer found the body-mass index 
(BMI) is the only criteria outside of the parameters, it is only slightly higher than recommended. Your other 
current medical issues may be affected adversely from untreated sleep apnea. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hypoglossal nerve stimulation have been met. Therefore, we decided that the 
Plan has to pre-approve hypoglossal nerve stimulation.  
 
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: 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary, the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility. 
 
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 documents do not support necessity for admission to an IRF and the complexity of 
the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitative 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Dalvance. 
 
You asked the Plan to pre-approve Dalvance. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Dalvance. Our reviewer says that the 
enrollee does not meet criteria for Dalvance. Our physician reviewer found Dalvance is not Food & Drug 
Administration (FDA) approved for the enrollee's diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research appearing in a Medicare-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 Dalvance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Dalvance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 sensor.  The Plan denied your request. The Plan says 
that you are requesting a CGM product that does not meet Medicare's definition of durable medical equipment 
(DME) and, therefore, is not in a defined Medicare benefit category. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
The records show that you are requesting coverage of a non-adjunctive CGM. As of January 1, 2023, the 
appropriate coding for a non-adjunctive CGM is E2103. The Freestyle Libre 3 is not specified as a product that 
may be billed using code E2103. Therefore, the Freestyle Libre 3 is not eligible for reimbursement.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label, 
not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Retacrit is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a Medicare-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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Retacrit (Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for the next level of 
care. You say that the enrollee has a life vest and cannot be safely discharged to another level of care other than 
an LTACH. You say that a skilled nursing facility cannot accommodate a life vest. The Plan denied your 
request. The Plan says an LTACH admission is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis without osteoporotic fracture. The documentation does not support that the 
enrollee has tried and failed Zoledronic acid. The documentation does not support that Zoledronic acid would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 10, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals. 
 
You asked the Plan to pre-approve the home delivered meals. You say that you believe home delivered meals 
should be covered because you have a disability and also diabetic. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home delivered meals have not been met. Specifically, home delivered meals is an excluded 
service. Therefore, we decided that the Plan does not have to pre-approve home delivered meals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. The Plan denied your request. The Plan says 
you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring provided on September 
24, 2022. 
 
You asked the Plan to pay for the remote physiologic monitoring. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the remote physiologic 
monitoring provided on September 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 12, 
2022, to July 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $370 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $740 ($370 x 2 days = $740). This item/service falls within the inpatient 
hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care 
provided on July 12, 2022, to July 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for OTC at-home COVID-19 testing kits purchased on 
April 24, 2022. 
 
You asked the Plan to reimburse for OTC at-home COVID-19 testing kits. You say that you should be 
reimbursed up to $50, this denial is in violation of the government directive. The Plan denied your request. The 
Plan says they are not responsible for reimbursing OTC COVID-19 at home test kits. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, over-the-counter (OTC) 
COVID-19 tests are covered by Original Medicare, so Medicare Advantage plans are not responsible for 
reimbursement of these test.  
 
We looked at the file and Medicare rules. Based on this information, we decided that since the OTC at-home 
COVID-19 testing kits were purchased after April 3, 2022, the Plan is not responsible for reimbursement of 
them. Please contact the Plan for more information about how to request reimbursement from Original 
Medicare. Therefore, we decided that the Plan does not have to reimburse for OTC at-home COVID-19 testing 
kits purchased on April 24, 2022.