Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection.  
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a sacroiliac joint 
injection is not medically necessary.  
 
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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low 
back pain and has a history of hypertension, multiple sclerosis, and fibromyalgia. However, there is no 
documentation of the degree and duration of pain relief from the prior injection. These must be documented 
before the appropriateness of another injection can be evaluated. Therefore, the request for a sacroiliac joint 
injection is 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the second pair of eyeglasses. We decided that the Plan does not have 
to pay for the first pair of eyeglasses.  
 
You asked the Plan to pay for the two pairs of eyeglasses provided on November 11, 2022. You say that you 
urgently needed the second pair of glasses, and they were not ready yet. You say you went to another optional 
center and had another pair made. You say you never received the eyewear, and you should not have to pay for 
it. The Plan says that the claim processed correctly. 
 
We decided that the Plan has to pay for the second pair of eyeglasses.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide evidence showing that you were charged 
for the second pair of eyeglasses. This means we cannot determine if the $149 you are being asked to pay is 
correct. Therefore, we decided that the Plan has to pay for the second pair of eyeglasses.  
 
We also decided that the Plan does not have to pay for the first pair of eyeglasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $400 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the $400 allowance towards the first 
pair of eyewear, which exhausted the benefit. This means you are responsible for the remaining $41 balance. 
Based on this information, we decided that the Plan's rules for coverage of the first pair of eyeglasses have been 
applied correctly. Therefore, we decided that the Plan does not have to pay for the first pair of eyeglasses. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that the medication is medically necessary to prevent the 
risk of a heart attack and a stroke. The Plan denied your request. The Plan says the records do not show that 
that you have tried the preferred drug Praluent and it hasn't worked or that you have medical conditions that 
prevent you from taking it.  
 
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 Leqvio. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation does not support that 
Praluent would likely be less effective or would likely have adverse effects for you. Your records do not show 
that you have tried and failed the preferred drug Praluent as part of the requirement of the plan before an 
approval for Leqvio can be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have colon cancer at this time and there would be no support to the 
use of Keytruda. The provided diagnosis does not meet UM requirements and is not medically accepted by 
Medicare compendia. 
 
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 Keytruda. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the health plan denied coverage for the Keytruda stating that the available medical records do not support the safety, efficacy and necessity of the drug 
as defined by Medicare criteria. The denial is being appealed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) Store on February 23, 2023.  
 
You asked the Plan to waive the coinsurance for CPAP. You say that the monthly charge will cause an 
economic hardship. 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 covered items and related supplies for durable medical equipment (DME) and related supplies. 
Covered items include, but are not limited to wheelchairs, crutches, powered mattress systems, diabetic 
supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating 
devices, PAP therapy and oxygen equipment, nebulizers, and walkers. The provider billed in the amount of 
$81.75 and the allowed amount is $27.40 for the service. $27.40 x 20% = $5.48. The provider also billed in the 
amount of $273.93 and the allowed amount is $83 for the service. $83 x 20% = $16.60. For both services, 
$5.48 + $16.60 = $22.08. Therefore, results in the total cost sharing amount of $22.08. 
 
You have been asked to pay a 20% coinsurance for CPAP. This item/service falls within the durable medical 
equipment (DME) and related 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 coinsurance 
for continuous positive airway pressure (CPAP) Store on February 23, 2023.
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 are concerned that without SNF services your 
condition will worsen. The Plan denied your request. The Plan says your condition does not meet the 
requirements for admission to a SNF.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve a SPRINT peripheral nerve stimulator. 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 peripheral nerve stimulators 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 SPRINT peripheral nerve stimulator. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is an 
ongoing clinical trial of Sprint PNS for low back pain and sacroiliitis. 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 SPRINT peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator (64555).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Libtayo. 
 
You asked the Plan to pre-approve Libtayo. 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 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 Libtayo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested use of Libtayo is not FDA-
approved for the enrollees diagnosis. It is indicated in enrollees with Programmed Cell Death Ligand 1 (PD-
L1) expression with tumor proportion score greater than or equal to 50% which is not in this case. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Libtayo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan with CT scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. The Plan denied your request. The Plan says a 
PET scan with CT scan is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan with CT scan. Our reviewer 
says that that the requested PET scan with CT scan is not medically necessary. Our physician reviewer found 
that the enrollee has stage 1b malignant melanoma on the right thigh. There were no palpable nodes and 
sentinel node biopsys that had been done. Therefore, without a sentinel node biopsy showing a tumor the 
request for a PET scan with CT scan 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 PET scan with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a PET scan with CT scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 12, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $345 copayment per day, for days 1 to 5 and a $0 copayment for additional days for in-network 
Medicare-covered hospital care each time you are admitted.  
 
The enrollee has been asked to pay a $345 copayment per day, for days 1 to 4 of the inpatient hospital stay. The 
enrollee has been asked to pay a total of $1,380 ($345 copayment x 4 days = $1,380). You have not been 
charged for any additional days. This item/service falls within the inpatient hospital care benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 12, 
2022, to February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tracheostomy shower covers (A7523). 
 
You asked the Plan to pre-approve the tracheostomy shower covers. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is an item of convenience. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the tracheostomy shower covers (A7523).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are recovering from a hip fracture and require 
IRF services to regain your prior level of functioning. The Plan denied your request. The Plan says the request 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 8, 2023, to 
February 10, 2023. 
 
You asked the Plan to pay for the medication. You say that there should not be anything owed to the hospital. 
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 self-administered drugs provided 
from February 8, 2023, to February 10, 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 self-administered drugs provided from January 16, 2023, to 
January 17, 2023. 
 
You asked the Plan to pay for the medication. You say that you only have one insurance company that handles 
prescriptions as well. 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 self-administered drugs provided 
from January 16, 2023, to January 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 You asked the Plan to pre-approve the injections. You say that the injections are medically necessary to 
improve the enrollee's quality of life. The Plan denied your request. The Plan says the face joint injections are 
not medically necessary. 
 
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 injections. Our reviewer says that 
that the enrollee does not meet the coverage criteria Our physician reviewer found that the enrollee has 
radicular symptoms and pathology on the imaging that corresponds to disc disease. The enrollee also has not 
had trials of conservative therapy. The request for the facet joint injections does not meet the LCD coverage 
criteria and therefore, is 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to provide any services for 
themselves and would require 24/7 assistance for life goals. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee's needs can be met 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.