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 services are 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. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy, but the documentation does not 
support that the enrollee's functional status or activity tolerance requires an 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: 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 if the enrollee does not complete therapy, he will not 
be able to go home because he is at risk for falls, and on blood thinner. The Plan denied your request. The Plan 
says the IRF services 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 above. 
 
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. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is concern that the enrollee will not be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of a benign lesion (D7410). 
 
You asked the Plan to pre-approve the excision of a benign lesion. You say that you are not financially able to 
cover the cost of this service. The Plan denied your request. The Plan says this service is not covered under 
your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
excision of a benign lesion (D7410).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT scan, abdomen and pelvis; without contrast 
material in one or both body regions, followed by contrast material(s) and further sections in one or both body 
regions (CPT Code 74178). 
 
You asked the Plan to pre-approve the CT scan. You say that the scan is necessary. The Plan denied your 
request. The Plan says the scan is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our physician reviewer 
found the review has determined that there is no specific clinical rationale for the requested CT scan of the 
abdomen/pelvis. The current body of peer-reviewed medical literature and practice guidelines do not support 
the use of CT of the abdomen and pelvis in the evaluation of patients with unexplained anemia. The requested 
CT of the abdomen/pelvis 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CT scan, abdomen and pelvis; without contrast material in one or both body regions, 
followed by contrast material(s) and further sections in one or both body regions (CPT Code 74178).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
IMRT does not offer an advantage over conventional or 3D conformal radiation therapy techniques. 
 
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 pre-approve the requested services. Our physician 
reviewer found that this case is somewhat challenging in that if the enrollee were to have only received a 
palliative dose of 30 Gy in 10 fractions, IMRT would not be needed, as such a dose is low, and sparing a strip 
of normal skin would be feasible with tangential fields. However, this patient ultimately received a high 
cumulative dose of 50 Gy in 25 fractions to be followed by a boost, for which sparing a portion of the limb is 
more important, as is delivering a more homogeneous dose delivery. There is a comparison plan (3D conformal 
versus IMRT), and DVH that shows IMRT lowering the mean dose to the tibia and fibula and on my review of 
the isodose lines, it is evident that the IMRT plan delivers a more conformal convex dose distribution. From the 
provided records, IMRT is plausibly a more effective manner to treat the target and to spare the surrounding 
normal tissues than 3D conformal radiation, which is supported by published data (reference 6). Therefore, the 
need for IMRT is adequately justified in the case records. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve Intensity Modulated Radiation Therapy (IMRT).  
 
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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from a stay at an acute 
IRF. The Plan denied your request. The Plan says the request for an IRF admission does not meet medical 
necessity criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the record supports a need for 
speech, physical and occupational therapy, it does not support a need for an intensive rehabilitation therapy 
program. Our physician reviewer also found that there is not a reasonable expectation that this 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar kyphoplasty L4 (22514). 
 
You asked the Plan to pre-approve a lumbar kyphoplasty L4. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered when specific criteria is 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 lumbar kyphoplasty L4. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found Medicare guidelines have not 
been fully met. There is no documentation of multidisciplinary team consensus including a neurologist. 
Therefore, the enrollee has not fully met the criteria for the requested lumbar kyphoplasty at L4. 
 
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 lumbar kyphoplasty L4 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar kyphoplasty L4 (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred 
drugs and does not detail any reason why the plan preferred drugs would be unsafe or ineffective 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec ODT 75mg tablets. 
 
You asked the Plan to pre-approve Nurtec ODT. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Nurtec ODT 75mg tablets.  
 
Benefits for Nurtec ODT 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's ability to regain maximum function is 
in jeopardy if not approved for rehab. The Plan denied your request. The Plan says that records do not support 
that the member can tolerate 3 hours of daily intense therapy or that the member requires complex intensive 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. 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 was admitted for confusion and 
anasarca. There are no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the record supports a need for physical and occupational therapy, it does not support a 
need for an intensive rehabilitation therapy program. 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. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee has been suffering from chest pain and 
an ongoing cough. The Plan denied your request. The Plan says the denial of authorization for this CT scan is 
correct, because there is no record of a detailed examination being done by the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found there is 
no specific clinical rationale for the requested CT scan. The chest X-Ray is normal, and the enrollee should 
undergo evaluation of other possible causes of pain prior to advanced imaging. This should include a 
cardiology and/or gastroenterology evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Computed Tomography (CT) scan of the chest.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Fluocinolone Acetonide injection (ILUVIEN). 
 
You asked the Plan to pre-approve the ILUVIEN. You say that you feel ILUVIEN would improve the 
enrollee's vision. The Plan denied your request. The Plan says that the enrollee does not meet the clinical 
criteria for coverage. The Plan also says that the enrollee does not have a cup to disc ratio of greater than 0.8. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the ILUVIEN. Our reviewer says that 
ILUVIEN is medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee is 
treated for refractory diabetic macular edema that has persisted in spite of more common intravitreal treatments 
(aflibercept and dexamethasone).  ILUVIEN carries a contraindication in patients with high cup/disc ratio 
(>0.8) because it is an indicator for glaucoma, and intravitreal steroids can cause elevation of intraocular 
pressure in some cases.  Our reviewer found that study protocols for intravitreal fluocinolone excluded patients 
with cup/disc > 0.8 because it is a potential indicator for poorly controlled or severe glaucoma.  The labeled 
contraindication is a reflection of that. Our physician reviewer also found that in spite of the food and drug 
administration labeled contraindication for cupping, there is no medical reason to withhold this drug from an 
enrollee with well controlled glaucoma, especially in a case like this, where the enrollee has demonstrated no 
increase in pressure after other intravitreal steroid treatments. 
 
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 ILUVIEN have been met. Therefore, we decided that the Plan has to pre-
approve Fluocinolone Acetonide injection (ILUVIEN).  
 
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 Denosumab (Prolia). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is unable to take oral medications due to 
the risk of gastrointestinal bleed. You also say that the enrollee is unable to take Reclast due to atrial 
fibrillation. The Plan denied your request. The Plan says the records that the provider submitted did not reflect 
contraindications, or attempted therapy using a bisphosphonate drug. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Denosumab (Prolia).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and implant supported crown 
(D6066). You say that you want to know why a crown is covered instead of a crown over an implant. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
custom fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Diclofenac Gel. 
 
You asked the Plan to pre-approve Diclofenac Gel. You say that the enrollee cannot take oral nonsteroidal anti-
inflammatory drugs. The Plan denied your request. The Plan says coverage of this medication is the 
responsibility of the enrollee's prescription drug 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 Diclofenac Gel.