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

 
We decided that the Plan does not have to pre-approve nivolumab, pemetrexed, paclitaxel, carboplatin, and 
Vitamin B12. 
 
You asked the Plan to pre-approve nivolumab, pemetrexed, paclitaxel, carboplatin, and Vitamin B12. You say 
that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says there is no guideline support for using these drugs together as a treatment 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 nivolumab, pemetrexed, paclitaxel, 
carboplatin, and Vitamin B12. Our reviewer says that the criteria for coverage have not been met.  Our 
physician reviewer found the enrollee has a stage IIIB non-small cell lung cancer, adenocarcinoma with minor 
features of squamous cell carcinoma. Next Generation Sequencing (NGS) showed an epidermal growth factor 
receptor (EGFR) mutation. The plan was for treatment with nivolumab, pemetrexed, paclitaxel, carboplatin, 
and Vitamin B12.  Per the National Comprehensive Cancer Network (NCCN) Guidelines, treatment with 
EGFR and tyrosine kinase inhibitors (TKIs) as single agents is indicated for the initial management of patients 
whose tumors contain an activating mutation in EGFR. This is preferred over chemotherapy- and 
immunotherapy-based approaches for patients with an identified driver mutation.  In addition, the enrollee is 
not considered a surgical candidate given extent of nodal involvement and would not meet criteria for 
neoadjuvant treatment. The requested drug regimen is not FDA-approved for the enrollees diagnosis. The use 
of this drug regimen is not supported by one of the major drug compendia or by clinical research that appears 
in a Medicare-approved medical journal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nivolumab, pemetrexed, paclitaxel, carboplatin, and Vitamin B12 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve nivolumab, pemetrexed, paclitaxel, 
carboplatin, and Vitamin B12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare Part B prescription drugs and an 
outpatient surgery provided on May 18, 2023. 
 
You asked the Plan to waive the copayment for Medicare Part B prescription drugs and an outpatient surgery. 
You say that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs and a $185 copayment for outpatient surgery.  
 
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $185 copayment 
for an outpatient surgery. The total allowed amount for the prescription drugs is $640.53. You are being asked 
to pay $128.10 ($640.53 x 20% = $128.10). However, you are only being asked to pay $50 for the outpatient 
surgery which is less than the required amount. The total amount you are being asked to pay $178.10 ($128.10 
+ $50 = $178.10). This item/service falls within the Medicare Part B prescription drugs and outpatient surgery 
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 Medicare Part B prescription 
drugs and an outpatient surgery provided on May 18, 2023.
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 ENROLLEES ARGUMENT-IRF The Plan denied 
your request. The Plan says PLAN'S ARGUMENT  IRF  
 
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 1ST the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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 total disc arthroplasty and exploration of spinal fusion 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve total disc arthroplasty and exploration of spinal fusion. You say that the 
services should be covered. The Plan denied your request. The Plan says this is available in-network. 
 
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 
total disc arthroplasty and exploration of spinal fusion to be provided by an out-of-network (OON) provider.
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 needs to be transferred to the 
LTACH to regain maximum/prior level of functioning. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
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 unstable for transfer and requires additional acute care services 
that can safely be provided at the current facility. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the PainTEQ LinQ Device for a sacroiliac (SI) fusion. 
 
You asked the Plan to pre-approve  the PainTEQ LinQ Device for a sacroiliac fusion. You say that the surgery 
is medically necessary and meets all the Center for Medicare and Medicaid Services (CMS) requirements.  The 
Plan denied your request. The Plan says the PainTEQ LinQ Device for the SI fusion is not medically necessary. 
The Plan says the device is investigatory and experimental.  
 
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 PainTEQ LinQ Device for a 
sacroiliac fusion. Our reviewer says that the requested surgery is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the LinQ device is experimental. SI joint fusion for 
degenerative back pain without instability is considered experimental.  
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 PainTEQ LinQ Device for a sacroiliac fusion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve  the PainTEQ LinQ Device for a sacroiliac (SI) fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the CGM. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as the claim has yet to be 
received. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the CGM has yet to be received. This means that more than one calendar 
year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not 
have to pay for a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services. You say that the services should be covered. The 
Plan denied your request. The Plan says this is available in-network. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B Prescription Drugs 
provided on February 13, 2023. 
 
You asked the Plan to waive the cost share for Medicare Part B Prescription Drugs. You say that you disagree 
with the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs. The total allowed 
amount for the prescription drugs is $21,461.17. You are being asked to pay $4,292.23 ($21,461.17 x 20% = 
$4,292.23). However, you hit your out-of-pocket maximum of $3,900. The total amount you are being asked to pay is $3,885. This item/service falls within the Medicare Part B Prescription Drugs 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 cost share for Medicare Part B Prescription Drugs provided on February 
13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freedom Peripheral Nerve Stimulator (PNS) system 
trial (64555 x 2). 
 
You asked the Plan to pre-approve a Freedom PNS system trial. 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 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 Freedom PNS system trial. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy at this time and the procedure is the 
subject of ongoing clinical trials. The enrollee is not enrolled in a clinical trial. 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 a Freedom PNS system trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freedom Peripheral Nerve Stimulator (PNS) system trial (64555 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. 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 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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines for adult stroke rehabilitation and recovery designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. In addition, provided records report spastic hemiplegia of the upper extremity; spasticity may be a contraindication to use of the device. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for the power wheelchair (E0956, E1028, 
E2359, E2374, E2392, K0108, K0739). 
 
You asked the Plan to pre-approve repairs for the power wheelchair. You say that the repairs are necessary. 
The Plan denied your request. The Plan says the cost of the requested repairs exceeds the cost of a replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that the repairs are necessary. The Plan denied your 
request. The Plan says the cost of the requested repairs exceeds the cost of a replacement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repairs for the power wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repairs for the power wheelchair (E0956, E1028, E2359, E2374, E2392, K0108, K0739).
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 enrollee has a peg tube and anti-seizure 
medications have needed constant updating. The Plan denied your request. The Plan says the enrollee does not 
meet the SNF Medicare criteria. The Plan says that the services needed are now custodial care in nature. 
 
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 skilled nursing facility (SNF) care.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medical records submitted do not establish that the 
admission into Long Term Acute 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: 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 IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy 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 as 
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.