Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee spent several days in the 
hospital due to COPD and chronic respiratory failure exacerbation. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the ventilator.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee was recently hospitalized with an exacerbation of COPD and heart failure 
with reduced ejection fraction. The enrollee also has obstructive sleep apnea and severe obesity. The enrollee 
has home BiPAP but has not been using it because it is nonfunctional. An arterial blood gas (ABG) in the 
hospital was consistent with acute on chronic hypercarbic respiratory failure. The enrollee improved in the 
hospital with BiPAP.  There are no pulmonary function tests to assess the severity of the COPD. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 4 miles for a total of 54 miles. 
 
You asked the Plan to pre-approve addition miles.. You say that you need additional 4 miles added to the 
approved 50 miles for a total of 54 miles routine transportation The Plan denied your request. The Plan says 
exceeds the max benefit. 
 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 routine transportation when each one-way trip must not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional 4 miles for a total of 54 miles.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. 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 mobility devices 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 motorized scooter. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record does not indicate you 
require a powered scooter to manage self-care in the home. 
 
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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that  the medical records support the medical 
necessity for the home ventilator.  The Plan denied your request. The Plan says based on Medicare guidelines, 
the noninvasive ventilator requested does not meet the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 the home ventilator. Our reviewer says 
that the requested item is not medically necessary. Our physician reviewer found the enrollee has COPD with 
chronic respiratory failure and as his hospitalization shows, benefited from BiPAP therapy. There is no 
indication or documentation that the enrollee failed BiPAP therapy. There is no indication that the home 
ventilator is required. The enrollee does not qualify for oxygen and would benefit from BiPAP, given the 
review of arterial blood gas (ABG )and the documentation provided. However, the enrollee does not meet best 
practice guideline for the home ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography angiography (CTA) services. 
 
You asked the Plan to pre-approve the CTA services. You say that the requested CTA is medically necessary. 
The Plan denied your request. The Plan says that the criteria for a CTA scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the CTA services. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the enrollee presented with pale 
feet. He has a history of atrial fibrillation, coronary artery disease, and chronic venous insufficiency with 
edema of lower extremities. He had vein ablation therapy and continues to have aching with ambulation. On 
the note from October 11, 2023, it is documented that he has exertional pain similar to claudication and his 
ankle brachial index (ABI) on the left lower extremity (LLE) is abnormal. The CTA was ordered for further 
work-up. Given the claudication pain and abnormal ABIs, a CTA is indicated in this patient.   
 
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 CTA services have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography angiography (CTA) services.  
 
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 an IRF stay to be provided by an OON provider.  
 
You asked the Plan to pre-approve an IRF stay by an OON provider. You say that admission to an IRF if 
medically necessary. The Plan denied your request. The Plan says the services are not authorized because the 
provider is out-of-network. The service can be provided by an in-network provider. 
 
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 
an IRF stay to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for a CT scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is asymptomatic from a 
cardiovascular standpoint. Current evidence showing that the use of coronary artery calcium (CAC) scores in 
clinical management of asymptomatic individuals leads to changes in patient management or in individual risk 
behaviors that improve cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management of this patient. As such, CT 
imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this patient's medical 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the heart.
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 requires skilled nursing for wound care 
and daily antibiotics. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage of SNF care. The Plan says that the enrollee's needs can be addressed at home. 
 
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 received oral medications, had stable vital signs, and had wound vac to 
her sacral ulcer twice weekly. The enrollee received physical therapy and occupational therapy. The enrollee 
was at an independent to contact guard assist level with functional mobility. The enrollee required varying 
assist with activities of daily living. There are no identifiable skilled nursing needs. There are identifiable 
skilled therapy needs, however they are not required on a daily basis. The enrollee does not meet the severity of 
illness criteria for an inpatient basis in a 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Platinol, Gemzar, and Opdivo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic urothelial 
cancer diagnosed in August of 2023. He has disease involving the liver. The use of Platinol, Gemzar, and 
Opdivo is not approved by the Food and Drug Administrtation (FDA) as first-line treatment for metastatic disease. The use is not supported by one of the major drug compendia or clinical research appearing in a 
Medicare-approved medical journal. The combination is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Platinol, Gemzar, and Opdivo.
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 services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says admission to IRF is not reasonable and 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: 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 services are medically necessary for the enrollee 
to receive therapy services and physician services to make functional gains. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for admission to an 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex. 
 You asked the Plan to pre-approve Darzalex. You say that the requested drug is medically necessary in treating 
multiple myeloma not having achieved remission. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements for the requested drug to be approved. 
 
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 Darzalex. Our reviewer says that the 
requested drug does not meet the criteria for approval. Our physician reviewer found the Plan requires the 
enrollee to have tried at least one prior therapy drug before they will approve the use of Darzalex; However, the 
enrollee has not had a prior drug therapy and the requested treatment, Darzalex in combination with bortezomib 
and dexamethasone, is not a standard first line regimen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Darzalex.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Test In Vitro Strip. 
 
You asked the Plan to pre-approve the Contour Next Test In Vitro Strip. You say that the enrollee has a 
diagnosis of diabetes and has been using the requested product since January of 2017. The Plan denied your 
request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Contour Next Test In Vitro Strip. Therefore, we decided that the Plan does not have to pre-approve 
Contour Next Test In Vitro Strip..
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 enrollee is having problems with their balance 
and strength. The Plan denied your request. The Plan says we do not see that the enrollee needs an inpatient 
setting to meet their needs.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for a neurogenic bladder and multiple sclerosis. 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 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D2740). 
 
You asked the Plan to pre-approve the dental service (D2740). You say that you are requesting reconsideration 
of the frequency denial due to being diabetic and 
needing treatment to avoid infection. The member states there will be hardship if required to pay out of pocket. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 8, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the dental service (D2740).