Persius/hicric huggingface dataset:
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 has had a traumatic brain injury and is 
awaiting approval to come to the IRF. The Plan denied your request. The Plan says the IRF services requested 
do not meet the requirements for approval.  
 
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 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: 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 would benefit from rehab under the 
supervision of a physician. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 unresectable 
hepatocellular carcinoma with a satellite nodule on the left. First line systemic treatment with Azetolizumab 
and Bevacizumab in April of 2023 with progression in June of 2023. The use of Keytruda is not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
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 a sacroiliac joint injection. You say that the enrollee would like 
reconsideration based on the records submitted. 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 sacroiliac joint injection. Our reviewer 
says that the enrollee does not meet the LCD coverage criteria. Our physician reviewer found that there is no 
documentation of at least three positive findings with provocative maneuvers including Faber, Gaenslen, thigh 
thrust, posterior shear, sacroiliac joint compression, sacroiliac joint distraction, and yeoman tests despite a 
minimum of four weeks of conservative therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain with 
radiation to the calves. She has had past physical therapy. She had three levels of kyphoplasty and imaging 
shows spinal stenosis and additional compression fractures. The criteria for coverage are met and the ESI is 
reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection (ESI).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is 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. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve dental services. You say that you need new dentures because your existing 
ones are poor quality. 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. This benefit includes the 
requested complete denture - maxillary (D5110) but replacement of a denture or a partial denture requires the 
existing denture to be 5+ years old. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered immediate denture  maxillary (D5130) and immediate denture  mandibular 
(D5140) on January 8, 2021. Although these are different services, they fall within the same category in your 
Schedule of Benefits and are subject to the same frequency limitations.  Therefore, these benefits were 
exhausted as of January 8, 2021. Therefore, we decided that the Plan does not have to pre-approve complete 
denture - maxillary (D5110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim NEO device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim NEO 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 Barostim NEO device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees clinical management. 
 
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 Barostim NEO device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim NEO device (0266T, C1825).
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 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD), though there are no pulmonary function tests to confirm airway obstruction and 
assess severity. He was admitted to the hospital in early June of 2023 with pneumonia and an arterial blood gas 
(ABG) was consistent with acute-on-chronic hypercarbic respiratory failure. He was later readmitted with 
worsened hypercarbic respiratory failure and diastolic heart failure. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. The criteria for coverage are not met and the ventilator is not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Injection, rituximab, 10 mg (J9312). 
 You asked the Plan to pre-approve drug, Injection, rituximab. You say that the enrollee was doing well but is 
now having worsening joint pain and swelling in the last few weeks. The Plan denied your request. The Plan 
says the records provided do not indicate the enrollee cannot take the preferred medications of Riabni 
(rituximab) and Truxima (rituximab) for arthritis. There is no documentation that the enrollee has failed the 
preferred products nor that the preferred products would cause adverse effect. 
 
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 drug, Injection, rituximab. Our 
physician reviewer found there is no documentation provided indicating that the plan's required drug(s) would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug, Injection, rituximab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve drug, Injection, rituximab, 10 mg (J9312).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure (HF) system. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs system was approved 
by the Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in the enrollee's clinical management.  
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 a CardioMEMs Heart Failure (HF) system.
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 admission is a medical necessity. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare 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 complexity of the enrollees nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee was admitted for weakness, dehydration, and failure to thrive. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the medical records support 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options, and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair (PWC) with multiple power options. You say 
that the enrollee is at increased risk for pressure injury and is not able to complete an effective weight shift. 
You also say that the recline is necessary for the enrollee's lower extremity spasticity. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for multiple power options. The Plan also says 
that it is not medically necessary to control the three requested power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria have been 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 Group 3 power wheelchair (PWC) 
with multiple power options. Our reviewer says that a Group 3 power wheelchair (PWC) with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation does not indicate 
that the enrollee is at high risk for skin breakdown, relies on a catheter or have spasticity limiting their position. 
The reviewer also found that the enrollee does not require alternative means of power control as evidenced 
through the ability to transfer independently, dress and feed themself. Therefore, the reviewer found that the 
requested Group 3 power wheelchair with multiple power options is not medically reasonable or 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 Group 3 power wheelchair (PWC) with multiple power options have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) 
with multiple power options, and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital and does not 
have to waive the copayment for outpatient hospital surgery services provided from February 13, 2023, to 
February 14, 2023. 
 
You asked the Plan to pay for the self-administered drugs and to waive the copayment for outpatient hospital 
surgery services. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. The Plan also says the cost sharing for the outpatient hospital surgery services 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 $250 
copayment for outpatient hospital surgery services. 
 
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. Also, you have been asked to pay a $250 copayment for outpatient hospital surgery services. 
This service falls within the outpatient hospital services 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 pay for 
self-administered drugs provided in the hospital and does not have to waive the copayment for outpatient 
hospital surgery services provided from February 13, 2023, to February 14, 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: Favorable

 
We decided that the Plan has to pre-approve Jemperli. 
 
You asked the Plan to pre-approve Jemperli. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says that the requested treatment is not considered medically necessary for the 
member'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 Jemperli. Our reviewer says that the 
medication requested is medically necessary. Our physician reviewer found the FDA has approved Jemperli for 
treatment of adult patients with mismatch repair-deficient recurrent endometrial cancer following the prior 
platinum-containing regimen such as in this case. The documentation supports that the requested drug is safe 
and effective and otherwise reasonable and necessary for the enrollees 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 Jemperli have been met. Therefore, we decided that the Plan has to pre-approve 
Jemperli.  
 
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.