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

 
We decided that the Plan has to pre-approve acupuncture services with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services with an OON provider. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services can be 
provided by an in-network provider. The Plan says that they were unable to determine if the contracted 
providers they recommend are accepting new patients. 
 
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. In this case, the Plan has not been able to confirm if the two in-network 
providers available to the enrollee are able to accept new patients. This means that the Plan has not ensured that 
the services are available and accessible under the Plan. Therefore, we decided that the Plan has to pre-approve 
acupuncture services with an out-of-network (OON) provider.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home infusion therapy on January 28, 
2023, to March 03, 2023. 
 
You asked the Plan to waive the coinsurance for home infusion therapy. You say that you want to appeal the 
amount being charged. 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 20% coinsurance for medical supply provider for home infusion therapy. Covered services include, 
but are not limited to professional services, including nursing services, furnished in accordance with the plan of 
care, patient training and education not otherwise covered under the durable medical equipment benefit, remote 
monitoring and monitoring services for the provision of home infusion therapy and home infusion drugs 
furnished by a qualified home infusion therapy supplier. The provider billed in the amount of $7,560 and the 
allowed amount is $994 for the service. $994 x 20% = $198.80. There were five service periods. 5 x $198.80 = 
$994. Therefore, results in the total cost sharing amount of $994. 
 
The enrollee has been asked to pay a 20% coinsurance for home infusion therapy. This item/service falls within 
the home infusion therapy 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 coinsurance for 
home infusion therapy on January 28, 2023, to March 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 record indicates that the enrollee has had a complicated hospital course and still 
has acute medical issues, requiring acute care services. The enrollee continues to receive acute care services, 
and these have not been denied. The medical record does not indicate that the enrollee requires services that 
they are not currently receiving but that would be available at the LTACH facility.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive the therapy and medical care that they need and deserve. 
 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: 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. 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 require treatment by multiple therapies. Medically necessary care 
can be provided in a lower 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral enteral formula and a bath/shower chair. 
 
You asked the Plan to pre-approve oral enteral formula and a bath/shower chair. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says enteral formula provided 
orally, and bath/shower chairs are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation 
or orally administered enteral nutrition products. Medicare rules also say that shower chairs are not covered 
because they are not primarily medical in nature.  
The items you asked the Plan to pre-approve are considered orally administered enteral nutrition products. 
Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Additionally, 
while a bath/shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve oral enteral formula and a bath/shower 
chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclosporine Emulsion. 
 
You asked the Plan to pre-approve Cyclosporine Emulsion. You say that the enrollee requires this drug to for 
the diagnosis of dry eye syndrome. 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 Cyclosporine Emulsion.  
 
Benefits for Cyclosporine Emulsion 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 pre-approve talimogene laherparepvec. 
 
You asked the Plan to pre-approve talimogene laherparepvec. You say that the medication is medically 
necessary. The Plan denied your request. The Plan says this drug is not recommended by the national 
comprehensive cancer network (NCCN). 
 
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 talimogene laherparepvec. Our 
reviewer says that the drug is not medically necessary. Our physician reviewer found the use of talimogene 
laherparepvec is not FDA approved for your diagnosis. The use of talimogene laherparepvec is not supported 
by one of the major drug compendia's or by the clinical research that appears in the centers for Medicare and 
Medicaid services (CMS)-approved medical journals. The use of talimogene laherparepvec cannot 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 talimogene laherparepvec have not been met. Therefore, we decided that the 
Plan does not have to pre-approve talimogene laherparepvec.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor for home use. 
 
You asked the Plan to pre-approve an automatic blood pressure monitor for home use. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for an automatic blood pressure monitor for home use. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat or masked hypertension 
and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat or masked hypertension. Although monitoring blood pressure 
in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in 
this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure 
monitor for home use.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom wheelchair and accessories. 
 
You asked the Plan to pre-approve a custom wheelchair and accessories. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says durable medical equipment, such as 
custom wheelchairs, are not covered by Medicare when the enrollee resides in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a custom wheelchair and accessories are being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a custom wheelchair and accessories.
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 you need to go to acute rehab to get better from after 
having a stroke. The Plan denied your request. The Plan says an IRF admission 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that the enrollee's mammogram showed extremely dense 
breast tissue and an MRI is needed for further evaluation. The Plan denied your request. The Plan says the MRI 
requested is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
requested MRI of the breast is not medically necessary. Our physician reviewer found that the last 
mammogram, on 01/19/2022, states that the breast is heterogeneously dense. There was no mass or 
calcifications, and no mammographic evidence of malignancy. Thus, it appears, the breast was examinable 
with mammogram and does not meet the requirements for breast MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient 
acute care and is currently unstable for transfer to an LTACH. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has multiple complex medical problems, is high risk for decompensation, and 
requires daily monitoring to prevent hospital readmission. The enrollee will require inpatient dialysis and at 
least a 25-day stay at an LTACH. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
March 30, 2023, to April 3, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you met your 
maximum out-of-pocket amount. 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 $225 
copayment for inpatient hospital care.  
 
The record shows you had not met your maximum out-of-pocket amount prior to this service. You have been 
asked to pay $225 copayment per day, for days 1 to 4 of the inpatient hospital stay. The total amount you owe 
is $900 ($225 copayment x 4 days = $900). You have not been charged for any additional days. This 
item/service falls within the inpatient hospital care 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 reduce the 
copayment for the inpatient hospital stay provided from March 30, 2023, to April 3, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (J1306). 
 You asked the Plan to pre-approve Leqvio. You say that you are requesting an appeal for medical coverage of 
Leqvio because the enrollee has a history of statin intolerance and has tried and failed these in the past. The 
Plan denied your request. The Plan says the enrollee does not have any stated contraindications to the preferred 
products, nor have they tried any of the preferred agents. The Plan also says the provider does not provide a 
rationale for use of the non-preferred product for safety or efficacy. 
 
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 
enrollee does not meet the coverage criteria for Leqvio. Our physician reviewer found the enrollee has not tried 
and failed the required drug. Our reviewer also found that there is no documentation provided indicating that 
the Plan's required drug 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 Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio (J1306).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that a CGM is medically necessary. The Plan 
denied your request. The Plan says that you do not meet Medicare criteria for a therapeutic CGM. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a therapeutic CGM. Our reviewer says 
that the item is medically necessary. Our physician reviewer found that although you are not using insulin and 
are not having low blood sugars, you have trouble using the glucometer that is based on fingerstick readings. 
As the a1c is high, blood sugar monitoring would help you control blood sugars better. The glucometer seems 
to be beyond your abilities to use reliably, a therapeutic CGM should be provided. 
 
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 therapeutic CGM have been met. Therefore, we decided that the Plan has to 
pre-approve a therapeutic CGM.  
 
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.