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

 
We decided that the Plan does not have to pre-approve treatment with carboplatin and docetaxel. 
 
You asked the Plan to pre-approve carboplatin and docetaxel. You say that the requested drugs are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested drugs have 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 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 carboplatin and docetaxel. Our reviewer 
says that the requested treatment regimen is not medically reasonable and necessary in this case. Our physician 
reviewer found tht the FDA 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 was submitted 
for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of carboplatin and docetaxel have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment with carboplatin and docetaxel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If the enrollee has severe chronic obstructive pulmonary disease (COPD) and chronic carbon 
dioxide (CO2) retention, may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep. This has not been tried and shown to fail. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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 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 a pneumatic compression device with associated leg 
sleeves (E0651 and E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device with associated leg sleeves to be provided 
by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your 
request. The Plan says the requested services are neither emergent nor urgent to seek OON care. The Plan says 
there are in-network providers available to the enrollee that can provide the items being requested. 
 
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 pneumatic compression device with associated leg sleeves (E0651 and E0667) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM. You say that you need the sensor because 
your glucose is going up and you would like to keep an accurate check before it goes in a dangerous zone. The 
Plan denied your request. The Plan says you are not on insulin; therefore, you do not meet the criteria for 
approval of the CGM. 
 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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
14-day continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the sacroiliac joint. You say that the requested 
radiofrequency ablation to the sacroiliac joint is medically necessary. The Plan denied your request. The Plan 
says the requested radiofrequency ablation to the sacroiliac joint is not medically necessary. 
 
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 radiofrequency ablation to the 
sacroiliac joint. Our reviewer says that the requested radiofrequency ablation to the sacroiliac joint is not 
medically necessary. Our physician reviewer found this is considered an experimental/investigational 
procedure due to the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is 
deemed not medically reasonable and 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 radiofrequency ablation to the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PWC. 
 
You asked the Plan to pre-approve a PWC. You say that you disagree with the denial for a power wheelchair. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 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 PWC. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the available documentation does not 
support that a power wheelchair is 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 a PWC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a PWC.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that the requested left heart 
catheterization is medically necessary. The Plan denied your request. The Plan says the requested left heart 
catheterization is not medically necessary. 
 
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 left heart catheterization. Our reviewer 
says that the requested left heart catheterization is not medically necessary. Our physician reviewer found the 
enrollee is with exertional dyspnea, and atypical chest pain for one year, and has been recommended to have a 
Left heart cauterization and coronary angiogram. The enrollee has already had a normal Nuclear Myocardial 
Perfusion scan, ruling out severe coronary artery disease. This enrollee with chronic dyspnea on exertion (DOE) and normal noninvasive work up DOES NOT benefit from this study as he has not been shown to fail 
Guideline Directed Medical Therapy for 12 weeks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the member does not meet Medicare criteria for an IRF admission. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
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. Medically necessary care can be provided in a different 
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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RhinAer procedure (30117). 
 
You asked the Plan to pre-approve a RhinAer procedure. You say that he requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says he requested services are 
experimental/investigational. 
 
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 a RhinAer procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is insufficient literature to support the safety and efficacy of the requested 
procedure for the enrollee's clinical condition 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 a RhinAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a RhinAer procedure (30117).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services.  
You asked the Plan to pre-approve private duty nursing services. You say that the services are necessary. The 
Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services are covered under certain 
conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of private duty nursing services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve private duty nursing 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns 
and a potential for functional improvement however, the documentation does not support that you would meet 
criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require 
skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy and occupational therapy to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient physical therapy and occupational therapy to be provided by an 
OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. 
The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan's 
says there are multiple in-network providers available to you that can provide the services you are requesting, 
including two providers who are less than 15 minutes from where you are staying with your daughter. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from where you are staying who can provide outpatient physical 
therapy and occupational therapy. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy and 
occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that the requested Gel-One is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Monovisc, Orthovisc, Synvisc, or 
Synvisc One first. 
 
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 Gel-One. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
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 member's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the member does not meet the requirements for an 
IRF admission. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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 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.