Persius/hicric huggingface dataset:
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 IRF care is medically necessary because you are in 
the hospital but needs to have rehab. You say that if you go home you will fall because you are not strong. The 
Plan denied your request. The Plan says IRF care is not medically necessary because 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found yhe 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 
facial fracture after a fall. 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 the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve carboplatin (J9045), docetaxel (J9171), trastuzumab-anns 
(Q5117), pertuzumab (J9306), palonosetron (J2469), and pegfilgrastim-bmez (Q5120). 
 
You asked the Plan to pre-approve the drug regimen. You say that the requested regimen is medically 
necessary. The Plan denied your request. The Plan says that the requested regimen is not supported for the 
enrollee's diagnosis. 
 
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 drug regimen. Our reviewer says 
that the requested drug regimen is medically necessary. Our physician reviewer found that the Food and Drug 
Administration has not stated that the requested drugs are indicated for the enrollee's condition. The Medicare 
approved cancer drug compendium, National Comprehensive Cancer Network database contains a supportive 
citation for the use of the requested drugs in the enrollee's clinical situation and states that the requested drugs 
are the preferred regimen with (cT1c, cN0, cM0, G3, ER-, PR-, HER2 positive disease. Therefore, the reviewer 
found that the requested drug 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 the drug regimen have been met. Therefore, we decided that the Plan has to pre-
approve carboplatin (J9045), docetaxel (J9171), trastuzumab-anns (Q5117), pertuzumab (J9306), palonosetron 
(J2469), and pegfilgrastim-bmez (Q5120).  
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
denial and have provided medical records. The Plan denied your request. The Plan says based on Medicare 
guidelines the long-term acute care hospital services you are requesting do not meet the requirements for 
approval. 
 
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 the enrollee was admitted with acute hypoxic respiratory failure in the setting of 
sepsis from lower extremity cellulitis, myocardial infarction, and acute kidney injury. The record indicates that 
the enrollee remains acutely ill and still requires acute care services before transitioning to a lower level of 
care. The medical record does not indicate that the enrollee requires services 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 the LTACH 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 you require acute care. You also say that you are not 
able to travel. The Plan denied your request. The Plan says IRF care is not medically necessary. 
 
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 provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while there is a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF admission is not medically reasonable 
or 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 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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. Your representative says you have an infection in 
your knee, methicillin-resistant staphylococcus aureus, urinary tract infection, and sepsis. You are also needing 
physical therapy and need cubicin to treat a bacterial infection. The Plan denied your request. The Plan says 
your medical record shows that you do not meet Medicare guidelines for care in a long-term acute care 
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 you were admitted with sepsis in the setting of an infected total knee arthroplasty. 
The record indicates that you are improving but still require acute care services before transitioning to a lower 
level of care. The medical record does not indicate that you require services 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone Gel. 
 
You asked the Plan to pre-approve Testosterone Gel. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Testosterone Gel.  
 
Benefits for Testosterone Gel may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit. 
 
You asked the Plan to pre-approve an office visit. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an office visit have been met. 
Specifically, medical records were not provided. Medical necessity cannot be determined without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve an office visit.
Appeal type: Step-Therapy
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 this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been bet. 
 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 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Psoriasis vulgaris. The Plan requires a trial of 2 of the following: Humira, Rinvoq, Skyrizi, 
Actemra (subcutaneous), Cosentyx, Otezla, Xeljanz or Xeljanz XR, Orencia (subcutaneous), and Enbrel before 
they will approve the requested drug. The enrollee has not tried and failed the required drugs. In addition, the 
case file contains insufficient documentation demonstrating that 2 of the following: Humira, Rinvoq, Skyrizi, 
Actemra (subcutaneous), Cosentyx, Otezla, Xeljanz or Xeljanz XR, Orencia (subcutaneous), and Enbrel, would 
likely be less effective, and/or would likely have adverse effects for the enrollee 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox (onabotulinumtoxinA) injection (J0585) and 
cystourethroscopy (52287). 
 
You asked the Plan to pre-approve the outpatient services. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says there was no trial of anticholinergic medications. 
 
The Plan follows Medicare rules. Medicare rules say that onabotulinumtoxinA is indicated for the treatment of 
overactive bladder (OAB) in adults and patients five years of age and older who have an inadequate response to 
or are intolerant of an anticholinergic medication. 
 
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 outpatient services. Our reviewer 
says that the requested injection does not meet the criteria for coverage. Our physician reviewer found the 
provided documentation does not indicate that the enrollee has had an inadequate response to or is not 
documented to be intolerant of an anticholinergic medication. Therefore, the reviewer found that the criteria for 
coverage have not been 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Botox (onabotulinumtoxinA) injection (J0585) and cystourethroscopy (52287).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the Plan requires 
a trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. In this 
case, the record indicates that the enrollee has iron deficiency anemia secondary to chronic blood loss in the 
setting of colon cancer. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on March 21, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were advised to submit the bill 
to insurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $180 
copayment for advanced imaging services, including CT scans.  
 
You have been asked to pay $158.02, which is less than the $180 copayment for the CT scan. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a computed tomography (CT) scan of the thorax provided 
on March 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on March 16, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were informed that the 
copayment would only be $15. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $75 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 a breast ultrasound provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided by The Portland Clinic on May 12, 
2022. 
 
You asked the Plan to pay for foot orthotics. You say that  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by The Portland 
Clinic on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
Volara system have not been demonstrated in the peer-reviewed literature for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Volara system have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Volara system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jazzy Evo power wheelchair (K0822). 
 
You asked the Plan to pre-approve a Jazzy Evo power wheelchair. 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 follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
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 Jazzy Evo power wheelchair. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
clinical documentation to determine the medical necessity of the requested Group 2 power wheelchair. There is 
insufficient documentation regarding the enrollees current function in terms of mobility and performing 
activities of daily living. The enrollee currently a has power wheelchair but the age of it is not provided. The 
documentation also indicates that the enrollee recently received a new power wheelchair, but the type of the 
power wheelchair is not provided. Lastly, there is no documentation regarding the enrollees motor strength 
and range of motion for his upper and lower extremities. Therefore, the Group 2 power wheelchair (Jazzy Evo) 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Jazzy Evo power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Jazzy Evo power wheelchair (K0822).