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

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that treatment with the requested drug is medically 
appropriate and necessary for your condition. The Plan denied your request. The Plan says the enrollee does not 
have any stated contraindications to the preferred products. The Plan says that the enrollee has not tried any of 
the preferred agents. The Plan says that there was no rationale for use of the non-preferred product for safety or 
efficacy.  
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 Ilumya. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug Humira, 
Endbrel or Skyrizi before they will approve the requested drug. In this case, the enrollee has not tried and failed 
the required drugs. There is no documentation provided indicating that the Plans required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found although the enrollee made slow progress with 
therapy, her functional improvement has plateaued, there is no indication that transfer to a skilled nursing 
facility is required. She can continue to receive skilled rehab services at the current IRF or be stepped down to 
a lower level of care.  
There are no services offered at a SNF that are not offered at an inpatient rehab 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020 V2784) provided on December 31, 
2021. 
 You asked the Plan to pay for the eyeglasses. You say that you were advised that this claim could be paid. The 
Plan denied your request. The Plan says this provider is not part of the specified vendor network. Out-of-
network services are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received through the Plans specified routine vision 
vendor. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified vendor 
network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020 V2784) provided 
on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit you had on September 20, 2021. 
 
You asked the Plan to pay for the visit. You say that this service should be covered because it was not coded 
correctly. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit you had on September 20, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to go to rehabilitation to get stronger and 
regain your maximum function before you can go to an assisted living facility. The Plan denied your request. 
The Plan says that authorization denied because SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
SNF care is medically necessary. Our physician reviewer found based on the documentation provided, you do 
qualify for SNF coverage. You do not have documented skilled nursing needs. You do have documented 
skilled therapy needs. You appear to be functioning below her baseline. The provided documentation does not 
establish that you have reached a new, lower, level of function. Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary caplet 195mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 caplet 195mg for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 16, 2021, to August 
22, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was in inpatient care during these 
dates, then transferred to hospice where he later expired. The Plan denied your request. The Plan says the 
enrollee was discharged to hospice care on August 22, 2021; therefore, this day does not count toward the total 
day count for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that the inpatient care provided on August 22, 2021, is not supported in the medical record. 
Specifically, the record shows that the enrollee was discharged to a different level of care on this date. Based 
on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. 
Therefore, we decided that the Plan does not have to pay for the inpatient care provided from August 16, 2021, 
to August 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the clinical records provided support the need 
for the surgery in dispute. The Plan denied your request. The Plan says the requested surgery is not supported 
because the prior spinal surgery did not help the enrollee's symptoms and now the symptoms have returned. 
 
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 spinal surgery. Our reviewer says that 
the requested spinal surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a medical history that includes low back pain and radiculopathy. There is no 
correlation between imaging and exam findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is a severe fall risk, and it is unsafe to 
return home. The enrollee may develop pneumonia without physical activity, as well as bed sores and stiffness 
of the hip joint without physical therapy. The Plan denied your request. The Plan says that authorization denied 
because SNF care is not medically necessary such as in long-term care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
SNF care is medically necessary. Our physician reviewer found based on the documentation provided, it is my 
opinion that the enrollee does qualify for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. Daily skilled services are required to 
establish a maintenance program and/or to prevent deterioration of the enrollees condition. The enrollees care 
needs, as a practical matter, cannot be provided at a lower level of care (ex. home health services, assisted 
living) given her dementia and need for weight bearing restrictions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 50 additional non-emergency transportation trips 
(A0120). 
 
You asked the Plan to pre-approve 50 additional trips. You say that the requested services are a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage have not been met because the 
annual 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 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 50 additional non-emergency transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested monitor is not medically reasonable or necessary. Our physician reviewer found the enrollee only 
takes one shot of insulin per day. The criteria would not be met. 
 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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is an experimental and 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment 
of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such 
as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase  participation in 
bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G device for the enrollee.
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 your current and previous medical conditions/issues 
warrant admission to an IRF. You say that you require intensive medical management by a team of doctors and 
nurses due to the complexity of your conditions and hospital stay. You say that you require intensive therapy to 
restore her overall function prior to discharging home. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the enrollee does not have complex medical 
conditions. The Plan says that the enrollee's needs can be met at an alternate 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for dysphagia and esophageal cancer. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee 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 the enrollee 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says that there is no need for intensive interdisciplinary rehabilitation support for 
this chronic condition. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for fluid overload and 
lymphedema. The enrollees medical problems are stable. There are 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. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi, Carboplatin, Etoposide and Dexamethasone 
sodium phosphate to treat primary pulmonary choriocarcinoma. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the drug/regimen is not being prescribed for a supported medically-accepted 
indication. The Plan states there is no NCCN (National Comprehensive Cancer Network) or Medicare 
approved literature support. 
 
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 the medication. Our physician reviewer 
found the requested use of Imfinzi, Carboplatin, Etoposide and Dexamethasone sodium phosphate to treat 
primary pulmonary choriocarcinoma is not FDA-approved for the enrollees diagnosis. The combination is 
approved for extensive stage small cell and the enrollee is described as having non-small cell lung cancer. The 
use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Imfinzi, Carboplatin, Etoposide and Dexamethasone sodium phosphate to treat primary 
pulmonary choriocarcinoma.