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

 
We decided that the Plan does not have to pre-approve mvasi (Q5107), pembrolizumab (J9271), paclitaxel 
(J9267), carboplatin (J9045). 
 
You asked the Plan to pre-approve the drug regimen. You say that the requested regimen is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested regimen is not 
approved by the FDA for the enrollee'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 the drug regimen. Our reviewer says 
that the requested regimen is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of endometrial cancer. The reviewer found that the Food and Drug Administration 
has not stated that the requested regimen is indicated for the enrollee's condition. The Medicare approved 
cancer drug compendia do not contain a supportive citation for the use of the requested drug combination in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested regimen 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 the drug regimen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve mvasi (Q5107), pembrolizumab (J9271), paclitaxel (J9267), carboplatin (J9045).
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 to the IRF is medically necessary. The 
Plan denied your request. The Plan says based on Medicare guidelines, 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 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 after experiencing altered mental status. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. The enrollee has had a decline from baseline level of function and would 
likely benefit from occupational and physical therapies but does not require the intensity of therapies provided 
on an acute inpatient rehabilitation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dextom G6. 
 
You asked the Plan to pre-approve the Dextom G6. The Plan denied your request. The Plan says the enrollee 
does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dextom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dextom 
G6.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting an expedited reconsideration 
for the denial of a SNF admission. You say the enrollee was independent before admission and now is not 
progressing each day, is new to oxygen and could be a fall risk at home. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for coverage of a SNF admission. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can be provided 
at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 your needs are not custodial, you recently fell and 
broke your arm while dislocating your shoulder. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan solution. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed multiple drops. 
You also say that the enrollee has been stable on Lumigan since 2018. 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 Lumigan solution.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablet. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has chronic nausea. You say that 
the requested medication allows the enrollee to eat. You also say that the enrollee needs to be able to eat 
normally in order to manage their condition. 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 ondansetron tablet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 You asked the Plan to pre-approve Aranesp. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Retacrit or 
Procrit. 
 
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 Aranesp. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate the enrollee has tried and failed one of the preferred drugs, Retacrit or Procrit. The reviewer found that 
the documentation does not support that Retacrit or Procrit would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria 
have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablet 4mg Odt. 
 You asked the Plan to pre-approve the medication. You say that you would like reconsideration based on the 
records submitted. 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. Although an oral anti-emetic such as ondansetron may be covered by Medicare Part B, this 
request does not fall under Medicare Part B coverage because it is not being used as a full therapeutic 
replacement for intravenous anti-emetics during a particular chemotherapy regimen. Therefore, we decided that 
the Plan does not have to pre-approve ondansetron tablet 4mg Odt.  
 
Benefits for ondansetron may be available through Medicare Part D. Please contact the health plan that 
administers the enrollees Medicare Part D benefits for more information about coverage and appeals.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on October 17, 2022. 
 
You asked the Plan to pay for the surgical services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says a valid clinical trial number was not billed on the claim for the billed 
clinical study and is a required item per Medicare guidelines. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. The claim was billed with 
a clinical study procedure, 02L73DK-Occlusion of Left Atrial Appendage with Intraluminal Device, 
Percutaneous Approach and was not billed with a clinical trial number. As a valid clinical trial number was not 
billed on the claim, we find the Medicare rule for payment of this inpatient facility claim has not been met. If 
the provider determines that a billing error occurred during the initial submission of the denied claim, the plan 
will accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on October 17, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0429-RH, A0425-RH) provided 
on October 15, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was transported from their home 
to the hospital twice on the date in question. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the medical records support that the 
enrollee was transported from their home to the emergency department twice on the date in question. There is 
no evidence that the Plan has already paid for each transport. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has to 
pay for ambulance transportation services (A0429-RH, A0425-RH) provided on October 15, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient revision L4-S1, posterior lumbar 
decompression and fusion and related procedures (22633), arthrodesis combined posterior or posterolateral 
technique (229634 and 22853), laminectomy, facetectomy, or foraminotomy with lumbar decompression of 
spinal cord, cauda equina, and/or nerve root during posterior interbody arthrodesis (63052 and 63053), 
allograft, morselized or placement of osteopromotive material ( 20930), and autograft for spine surgery only 
(20936). 
 
You asked the Plan to pre-approve the outpatient surgery. You say that the services are medically necessary. 
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 the outpatient surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Additionally, dynamic 
flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at 
the requested surgical level. Detailed documentation is not evident regarding potential impending/inevitable 
temporary intra-operative instability. Moreover, the provided diagnostic testing did not corroborate any 
hardware failure or significant pathology that would require revision surgery.  
 
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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the outpatient revision L4-S1, posterior lumbar decompression and fusion and 
related procedures (22633), arthrodesis combined posterior or posterolateral technique (229634 and 22853), 
laminectomy, facetectomy, or foraminotomy with lumbar decompression of spinal cord, cauda equina, and/or 
nerve root during posterior interbody arthrodesis (63052 and 63053), allograft, morselized or placement of 
osteopromotive material ( 20930), and autograft for spine surgery only (20936).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the member will clearly benefit from acute 
rehabilitation to optimize his level of functioning prior to returning home. The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services you are requesting 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 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 coronary artery bypass grafting. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio (inclisiran) injections. 
 You asked the Plan to pre-approve the Leqvio treatments. You say that it is felt that this drug should be 
approved. The Plan denied your request. The Plan says the enrollee can try the preferred drug. 
 
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 the Leqvio treatments. Our reviewer 
says that the requested treatment is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the Plan requires a trial of Repatha before approving coverage of Leqvio. The 
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the preferred step one alternative. 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 the Leqvio treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Leqvio (inclisiran) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre 2 Sensor and Freestyle Libre 2 Reader. 
 
You asked the Plan to pay for the CGM. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows 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 pay for the CGM. Our reviewer says that the 
requested CGM is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee is using Lantus twice per day and no dose adjustments are being made on a daily basis. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pay for a Freestyle Libre 2 Sensor and Freestyle Libre 2 Reader.