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

 
We decided that the Plan does not have to pre-approve dexamethasone sodium phosphate injection, 
fosaprepitant injection, ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide injection.  
 
You asked the Plan to pre-approve dexamethasone sodium phosphate injection, fosaprepitant injection, 
ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide injection. You say that the 
requested drug is medically necessary. The Plan denied your request. The Plan says the use of this 
drug/regimen is 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 dexamethasone sodium phosphate 
injection, fosaprepitant injection, ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide 
injection. Our physician reviewer found the use of dexamethasone sodium phosphate injection, fosaprepitant 
injection, ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide injection is not FDA-
approved for the enrollees diagnosis after progression on a programmed cell death ligand 1 (PDL1) inhibitor. 
It is also 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 dexamethasone sodium phosphate injection, fosaprepitant injection, 
ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide injection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve dexamethasone sodium phosphate injection, 
fosaprepitant injection, ondansetron hcl injection, carboplatin injection, durvalumab, and etoposide injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve superion interspinous spacer (vertiflex device) (22869 
and 22870). 
 
You asked the Plan to pre-approve superion interspinous spacer. You say that this service is the enrollee's best 
option as they have suffered with spinal stenosis for several years and they are not a candidate for surgical 
decompression. The Plan denied your request. The Plan says this service does not meet Medicare guidelines for 
approval. 
 
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 superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is considered experimental. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of superion interspinous spacer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve superion interspinous spacer (vertiflex device) (22869 and 22870).
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 medical records were provided to support 
authorization. The Plan denied your request. The Plan says the patient's needs can be met with a bilevel 
positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS). 
 
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. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found enrollee has a diagnosis of 
chronic obstructive pulmonary disease. The medical records submitted on appeal indicates that he was 
prescribed a non-invasive ventilator (NIV) on February 24th, 2023. The NIV was ordered in the AVAPs mode. 
With this request for continuation of the NIV, there was no change in the order for the device, or in the settings 
requested according to the standard written order dated March 6th, 2023. The compliance data submitted by the 
durable medical equipment provider from the time period of March 12th, 2023, to June 9th, 2023, indicates the 
machine is being used in AVAPS-AE mode, and no other modes. He saw his provider in the office on February 
6th, 2023, and March 1st, 2023, and the office visit notes do not mention the non-invasive ventilator. The 
documentation submitted fails to indicate that he is requiring the NIV for use in other than bilevel positive 
airway pressure (BiPAP) or BiPAP with AVAPS mode. The records we received do not say that the enrollee 
has failed the use of BIPAP or BIPAP with AVAPS when he is at his baseline level of breathing. The 
documentation indicates that this device is being used solely for AVAPS, and thus it is being used solely as a 
respiratory assist device. The documentation provided does not support that the use of a BiPAP device with 
AVAPS would not meet the patients current medical needs or has been found to be ineffective in the home 
setting. There is no supporting documentation that this NIV is being used as intended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pre-approval for a Group 3 heavy duty power wheelchair (K0858) and 
additional items and accessories (codes E1002, E2300, E2621, E2311, and E2608). 
 
You asked the Plan pre-approval for the Group 3 heavy duty power wheelchair and additional items and 
accessories. You say that your current scooter is too small for you, is falling apart, and no one is willing to 
service it. You also say that you feel the requested power chair will improve your quality of life significantly. 
The Plan denied your request. The Plan says the Group 3 power wheelchair criteria is not satisfied because you 
do not have a neurologic condition, myopathy or congenital skeletal deformity. The Plan also says that the 
requested accessories and cushions for the Group 3 power wheelchair are denied as well. 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have pre-approval for a Group 3 
heavy duty power wheelchair (K0858) and additional items and accessories (codes E1002, E2300, E2621, 
E2311, and E2608).
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 you need assistance to walk and is concerned about 
balance and falling. The Plan denied your request. The Plan says you do not require complex daily nursing care 
that must be provided in a skilled nursing facility. 
 
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 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 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 complex medical needs. The Plan denied your request. The Plan says you can safely receive the 
services needed in another setting such as a skilled nursing facility, home with home health and home with 
physical therapy. 
 
 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 you do 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: Favorable

 
We decided that the Plan has to pay for the inpatient admission services provided on October 21, 2022. 
 
You asked the Plan to pay for the inpatient admission services. You say that the records support medical 
necessity for the services that were rendered. The Plan denied your request. The Plan says that according to the 
records, the precertification entity was not contacted for precertification. 
 
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. The records do not support that the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the inpatient admission services. It is the burden 
of the Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated. 
Therefore, we decided that the Plan has to pay for the inpatient admission services provided on October 21, 
2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 74 additional trips for routine transportation. 
 
You asked the Plan to pre-approve 74 additional trips. You say that you need 74 one-way trips for several 
different appointments. The Plan denied your request. The Plan says this request would exceed the benefit 
allowance for the year. 
 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 a maximum of up to 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 74 additional trips for routine transportation.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says a trial of Avastin is required before alternatives can be considered. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the service 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on December 2, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON electrocardiogram. You say that you had been to this OON provider 7 
years ago due to a curved Aorta and they told you to return in 5 years. You say that you also went for a cough 
that no doctor in Buffalo had found the cause of. You say that the OON discovered what was causing the cough 
and referred you to a rheumatologist. You say that, had you not gone to see the OON provider, this need would 
not have been found. The Plan denied your request. The Plan says medically necessary care was available 
within the network. Prior authorization was not obtained for the OON services. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram provided on December 2, 
2022, by an out-of-network (OON) provider.
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 other devices do not have the settings that a 
ventilator has and the patient is in need of the special features. The Plan denied your request. The Plan says the 
patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured 
pressure support (AVAPS). 
 
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. 
 
 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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 64-year-old 
male with a history of chronic obstructive pulmonary disease (COPD). The submitted pulmonary evaluation 
includes arterial blood gas analysis (ABG) showing hypercarbia (pH 7.31, PaCO2 53, and PaO2 99). Complete 
pulmonary function testing (PFT) shows a severe obstructive ventilatory deficit with dynamic hyperinflation 
and a reduced diffusion capacity. A six-minute walk test (6MWT) does not show exertional desaturation on 
baseline oxygen flow of 5L/min. A request is now made for a home mechanical ventilator with PS with Safety 
Tidal Volume mode to assure adequate tidal volume ventilation. The addition of volume assurance may benefit 
this member and the need for positive pressure ventilation is not disputed. In summary, use of a portable 
ventilator (E0466) to deliver ventilatory support via settings that could be equally provided by a BiPAP with 
AVAPS settings is inconsistent with Medicare rules. The requested device would be used in a BiPAP mode 
that could be provided with a BiPAP (E0471) device with AVAPS added to assure adequate tidal volumes. A 
BiPAP device with AVAPS would meet all the needs requested. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says that this procedure 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee also has leg pain, and the exam shows facet loading pain. The cause 
of the enrollee's back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been to this IRF before and believe they 
would do a better job taking care of you. The Plan denied your request. The Plan says ongoing skilled care can 
be provided in an alternative setting.  
 
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 you do 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transport three 
times per week for dialysis. The Plan denied your request. The Plan says you have exhausted your routine 
transport 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 a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 100 routine transportation trips.