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

 
We decided that the Plan does not have to pay for the self-administered drugs from August 28, 2023, through 
August 29, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
August 28, 2023, through August 29, 2023.  
 
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260 x3) and bone replacement 
grafts (D4263 x3). 
 
You asked the Plan to pre-approve osseous surgery and bone replacement grafts. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the requested services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260 x3) and bone replacement grafts (D4263 x3).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services provided on July 31, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary to help after a fall. The Plan denied your request. The Plan says without 
transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 31, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services provided on July 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo infusions (in combination with Yervoy). 
 
You asked the Plan to pre-approve Opdivo infusions (in combination with Yervoy). You say that the enrollee 
does not have a good enough performance status to tolerate first-line therapy with Doxorubidn based therapy 
and there is concern about how she might tolerate it. The tumor is enlarging rapidly. The goal is to reduce the 
size of the tumor prior to surgery, as her disease is localized. She is undergoing concurrent radiation therapy as 
well. The Plan denied your request. The Plan says a review of the current medical literature shows that Opdivo 
infusions in combination with Yervoy infusions as first line therapy has not been found to be safe and effective 
for your condition. The criteria for medical necessity have not been met and the request for coverage of Opdivo 
infusions cannot be provided. 
 
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 Opdivo infusions (in combination with 
Yervoy). Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of retroperitoneal undifferentiated pleomorphic sarcoma. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition as 
prescribed. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug as prescribed in the enrollee's specific clinical situation. No literature from Medicare 
approved cancer journals were submitted for review. 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 Opdivo infusions (in combination with Yervoy) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Opdivo infusions (in combination with Yervoy).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from this level 
of care. The Plan denied your request. The Plan says the enrollee's needs can be managed at the current facility 
until they are more stable for transfer to another level of care. 
 
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 does not require services at the LTACH that are not already available at 
the acute care hospital. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient mental health services provided from April 13, 2023, to 
April 26, 2023. 
 
You asked the Plan to pay for the services provided. You say that the enrollee remained in care until she was 
safely discharged. The Plan denied your request. The Plan says that the services could be provided safely in 
other settings. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the plan provided notice 
that the services provided would not be covered. Under Medicare rules, this means the services provided is 
considered approved by the plan. Additionally, the enrollee cannot be asked to pay a copay when the Evidence 
of Coverage clearly outlines there is no copay for inpatient services. Therefore, we decided that the Plan has to 
pay for the inpatient mental health services provided from April 13, 2023, to April 26, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for a SNF admission. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services the enrollee require can safely be received at a different setting, for 
example, home with home health, in residential care, or home with close follow-up with their doctor. Under 
Medicare, the request 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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the requested injection is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested injection. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Orencia. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that based on the medical records provided 
there is no documentation that the Orencia at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Also, the provided records in this case do not document the Orencia 
will not be used with a Janus kinase inhibitor or a biologic DMARD, such as a tumor necrosis factor 
antagonist. It may be used as monotherapy or concomitantly with disease-modifying, antirheumatic drugs 
(DMARDs) other than Janus kinase inhibitors or biologic DMARDs, such as tumor necrosis factor antagonists. 
Provided records in this case do not document the Orencia will not be used with a Janus kinase inhibitor or a 
biologic DMARD, such as a tumor necrosis factor antagonist. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 31, 2023. 
 
You asked the Plan to pay for the services provided. You say that the testing should be reimbursed. The Plan 
denied your request. The Plan says providers that accept Medicare must be used. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 We looked at the file and the rules. A review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. If you go to a provider who is not eligible to participate in 
Medicare, you will be responsible for the full cost of the services you receive. However, as a courtesy, the Plan 
agreed to reimburse the Medicare allowed amount for the services provided. Therefore, we decided that the 
Plan does not have to further pay for the lab testing provided on March 31, 2023.
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 LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for foot orthotics.  
 
You asked the Plan to reimburse you for the foot orthotics. You say that you would like to be reimbursed for 
the foot orthotics you received. 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 reimburse you for foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you thought it would cost less to drive yourself to the hospital. The Plan denied your request. The Plan says 
without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on July 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that the enrollee had minimal response to Aranesp. You 
also say that the requested medication has been shown to be effective at reducing the need for transfusions 
when used in the treatment of MDS with or without ringed sideroblasts. The Plan denied your request. The 
Plan says this medication is not indicated for the enrollee's condition. 
 
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 Reblozyl. Our reviewer says that the 
requested use of Reblozyl is not medically necessary. Our physician reviewer found the requested use of this drug is not approved by the Food and Drug Administration (FDA) for the enrollee's condition. The reviewer 
found that the enrollee has refused a bone marrow biopsy. The reviewer also found that the requested use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested use 
of Reblozyl is not medically reasonable or necessary 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (J0896).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need SNF care as you are unable to stand up 
and walk. The Plan denied your request. The Plan says you do not meet the requirements for an SNF 
admission. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found, based on the medical records provided, there is no documentation that you require 
SNF services. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to 
safely and effectively provide medically necessary and reasonable treatment. While the records indicate there is 
a need for skilled therapy services, you do not require these services on an inpatient basis, only in a SNF 
setting. Records support that services in a long-term care facility on a part time basis are appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from August 30, 2023, through 
September 1, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
August 30, 2023, through September 1, 2023.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from July 12, 2023, through July 
13, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
July 12, 2023, through July 13, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.