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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care 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 complexity of the patient's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on August 08, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you were 
told the CT scan was covered in full prior to having it done. 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 $250 
copayment for outpatient diagnostic test, including CT scans. 
 
You have been asked to pay a $250 copayment for the computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test, including CT scans 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. However, since the allowed amount is less than the standard 
copayment, you only owe $239.13. Therefore, we decided that the Plan does not have to waive the copayment 
for the computed tomography (CT) scan provided on August 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intestinal obstruction procedure, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for intestinal obstruction procedure. You say that you are asking for a 
reconsideration of the denied claim. The Plan denied your request. The Plan says these services 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) 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 
intestinal obstruction procedure, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that the request is medically necessary. The Plan denied 
your request. The Plan says the requested use of this drug is not supported. 
 
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 Kanjinti. Our reviewer says that 
treatment with Kanjinti is not medically reasonable and necessary in this case. Our physician reviewer found 
that the requested use of Kanjinti is not FDA-approved for the enrollees 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve the medication. You say that the request is medically necessary. 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 pre-approve Humira.  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the best choice in 
executing the plan of care, as the enrollee's medical needs cannot be safely addressed in a skilled nursing 
facility (SNF). The Plan denied your request. The Plan says they will continue to cover medically necessary 
acute and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate 
level of care (such as a skilled nursing facility), or until the clinical circumstances change such that LTACH 
may be reconsidered. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested LTACH care is not considered medically reasonable and necessary in 
this case. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet 
stable for transfer and as it would not be clinically advantageous. Completion of treatment at the current facility 
is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis-adult (D1110), periodic oral evaluation (D0120) 
and bitewings-four radiographic images (D0274) provided on September 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 periodic oral evaluation was exhausted on date of service March 6, 2023, and April 
6, 2023. You have also reached your $1,000 annual maximum. Therefore, we decided that the Plan does not have to pay for prophylaxis-adult (D1110), periodic oral evaluation (D0120) and bitewings-four radiographic 
images (D0274) provided on September 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic manipulative treatment. 
 
You asked the Plan to pre-approve the chiropractic manipulative treatment. You say that you have been 
suffering from lower back pain for several months, which has greatly affected your life. You say that you can 
only walk 100 steps before you have to stop and take a break because you lower spine hurts and you can longer 
walk, which is making you depressed.  The Plan denied your request. The Plan says that there is no radiology 
study to support subluxation.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
  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 chiropractic manipulative treatment. 
Our reviewer says that the chiropractic manipulative treatment is not medically necessary. Our physician 
reviewer found that you have low back pain and radiculopathy. However, the records provided do not 
document the presence of subluxation either by a physical examination or radiographic images. Also, the 
records do not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. Therefore, the elements of the coverage criteria are not satisfied, and the requested service is 
not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the chiropractic manipulative treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the chiropractic manipulative treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain or ceramic crown (D2740) for teeth 23, 24, 
25, 26, 28, and 29. 
 
You asked the Plan to pre-approve porcelain or ceramic crown for teeth 23, 24, 25, 26, 28, and 29. You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says they denied this 
service because the x-ray your dentist does not show significant loss of tooth structure. Our physician reviewer 
also found that none of the teeth in question have any clear missing structure, and under the criteria presented 
there would be no coverage for crowns in this instance. 
 
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. The Plan covers porcelain or 
ceramic crown for teeth 23, 24, 25, 26, 28, and 29 when the services are medically necessary and reasonable.  
 
 
  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 porcelain or ceramic crown for teeth 23, 
24, 25, 26, 28, and 29. Our reviewer says that the enrollee does not meet the criteria for the requested service. 
Our physician reviewer found in this instance there is no structural damage noted and therefore no need for full 
coverage on any of the teeth in question. Our physician reviewer also found that  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of porcelain or ceramic crown for teeth 23, 24, 25, 26, 28, and 29 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic crown (D2740) for 
teeth 23, 24, 25, 26, 28, and 29.
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 you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 the 
documentation does not support that the requested drug does not meet step therapy criteria. Our physician 
reviewer found the enrollee has central retinal vein occlusion of the left eye with macular edema. The 
documentation does not support that the enrollee has tried and failed Byooviz. The documentation does not 
support that Byooviz would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode.  
 
You asked the Plan to pre-approve a spine nerve stimulator. The Plan denied your request. The Plan says a 
spine nerve stimulator is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation unless all of the 
conditions 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 spine nerve stimulator. Our reviewer 
says that a spine nerve stimulator is not medically necessary. Our physician reviewer found that the enrollee 
needs psychological clearance prior to a spinal cord stimulator placement trial. Therefore, the request 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 a spine nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous implantation of neurostimulator electrode.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam. 
 
You asked the Plan to pre-approve Octagam. You say that there is supporting data and research in current 
medical literature supporting the use of Intravenous Immunoglublin (IVIG) infusion therapy for the enrollee's 
condition. The Plan denied your request. The Plan says this treatment has not been proven to be helpful for the 
enrollee's condition. 
 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Octagam. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found this treatment has not been proven to be helpful 
for the enrollee's 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 Octagam have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation (HGNS). 
 
You asked the Plan to pre-approve HGNS. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that you do not meet LCD requirements for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulation may be covered under 
certain circumstances. 
 
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 HGNS. Our reviewer says that the 
requested service is not recommended. Our physician reviewer found the record indicates that you have 
obstructive sleep apnea and a body mass index of 38.5, which is greater than 35. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HGNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve HGNS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on August 
14, 2023. 
 
You asked the Plan to pay for the CGM supplies. You say that the documentation you provided does not 
support that all coverage criteria are met. The Plan denied your request. The Plan says you have provided 
documentation to support payment. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. In this case, the 'order' does not indicate the number of times per day 
that the enrollee tests their blood sugar, nor does it address whether or not the enrollee has hypoglycemic 
episodes. Further, the order does not indicate how frequently the enrollee uses insulin. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on August 
14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
rehabilitation stay. The Plan denied your request. The Plan says acute inpatient rehabilitation 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for MI Tumor Seek Hybrid testing (81479) provided on July 18, 2023. 
 
You asked the Plan to pay for MI Tumor Seek Hybrid testing. You say that this test was medically necessary 
and appropriate. The Plan denied your request. The Plan says that this test was not FDA approved for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for MI Tumor Seek Hybrid testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that enrollee has metastatic cancer and has not been previously tested using NGS 
and is continuing to receive therapeutic chemotherapy. The NGS testing with this provider/laboratory is FDA-
approved and provides report template to specify treatment options. The criteria are met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MI Tumor Seek Hybrid testing have been met. Therefore, we decided that the 
Plan has to pay for MI Tumor Seek Hybrid testing (81479) provided on July 18, 2023.  
 
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.