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

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, cervical; without 
contrast material (CPT Code 72141), for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the MRI is not 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 the MRI. Our physician reviewer found 
the x-rays and physical examination findings did not reveal an abnormality which might warrant a procedure or 
imaging with MRI. There was no documentation of the patient having been recently using physical therapy or 
other conservative treatments specifically for the neck which is required prior to considering imaging. 
Therefore, without sufficient support provided, MRI cervical spine will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, cervical; without contrast material (CPT Code 72141), for 
the enrollee.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to 
acute care after a fall and breaking a hip; imaging revealed a displaced right intertrochanteric hip fracture status 
post IM nailing. She is now touchdown weight bearing. Hospital course has included pain management. She is 
hemodynamically stable, and non-toxic. She is maximum assist for overall care. 
 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lesser level of care.  Ongoing pain medication and other medication management, wound care, 
and daily therapy can be provided at a lesser level of care. In this case, the member is mostly maximum assist 
for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow 
for measurable gains to be attained within a reasonable, and predicted period.  An IRF intensity is not 
warranted. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Therapeutic Plasma Exchange (plasmapheresis). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has tried multiple approved therapies 
for this diagnosis with minimal beneficial effect. You state the enrollee's condition is deteriorating which 
requires multiple excisions of the calcific deposits from different body parts and prolonged/multiple 
hospitalizations with delayed healing time and recovery. The Plan denied your request. The Plan says that this 
treatment is investigational at this time and does not meet Medicare criteria. 
 
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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has exhausted treatment options.  The Patient suffers significant morbidity from 
their calcinosis. Our doctor finds that it is indicated given limited options for therapy for systemic sclerosis and 
promising findings from use of this therapy. This particular complication is too rare to expect to find in 
literature a specific series justifying its use. It is medically reasonable to try this therapy. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve Therapeutic Plasma Exchange (plasmapheresis).  
 
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 Arenesp. 
 
You asked the Plan to pre-approve Arenesp (J0881). You say that you want the enrollee to be treated with this 
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Retacrit for at least two consecutive months with appropriate dose adjustment. 
 
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 Arenesp (J0881). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not tried 
and failed the required drug and there is no indication 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 Arenesp (J0881) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Arenesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy criteria is not met. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates 
that the plan requires a trial of zoledronic acid before they will approve the requested drug.  In this case, the 
patient has not tried and failed the required drug. 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. Step therapy 
criteria has 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hi-Fidelity Interface socket (L5999). 
 
You asked the Plan to pre-approve a HIFI socket. You say that this will efficiently control unwanted intrinsic 
skeletal movement and more effectively capture skeletal motion. The Plan denied your request. The Plan says 
this is experimental and does not have FDA approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HIFI socket. Our reviewer says that 
the requested HIFI socket is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this socket does not have FDA approval. While there is limited literature supporting the use of 
this socket interface system for transfemoral amputees, there is no literature regarding the use of this system for 
transtibial amputees. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of these procedures for you. This device appears to be experimental or investigational and has not been 
shown to be safe and effective in your situation. 
 
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 HIFI socket have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Hi-Fidelity Interface socket (L5999).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Lutathera 370mbq/ml solution. 
 
You asked the Plan to pre-approve the Lutathera. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says that there is currently no data, 
including major studies on the use of Molecular Target Agents for this 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 Lutathera. Our reviewer says that 
the use of Lutathera is supported by clinical research. Peptide receptor radionuclide therapy with lutetium-177 
isotope has been successfully used in other neuroendocrine tumors, and MCC also responds to the lutetium 
treatment. Our physician reviewer found the documentation supports that Lutathera is safe, effective and 
otherwise 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 the Lutathera have been met. Therefore, we decided that the Plan has to pre-
approve Lutathera 370mbq/ml solution.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 documentation provided shows that this patient requires additional acute care 
services and workup to complete their hospital course and stabilize the patient. Also, the clinical status does not 
suggest a likely need for acute care services for at least 25 days. The patient does not require any services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary at this time. Transfer may be considered at a later 
date workup is completed and the patient is stable. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF admission is medically necessary. The Plan denied your request. The Plan says the member is 
receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that Durolane 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 Durolane. Our reviewer says that 
Durolane is not medically necessary. Our physician reviewer found the record does not show any reason that 
one of the 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FlowerAmnioFlo Allograft Injection (CPT 20610/RT, 20610/LT, 77002 x2, Q4177 x2), for the enrollee.
You asked the Plan to pre-approve the services. You say that the patient has knee pain and is on opioid pain killers. You state that treatment has been approved in the past and you do not understand why it is not approved now. The Plan denied your request. The Plan says this is not covered by Medicare.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has a diagnosis of bilateral knee pain. Prior treatment has included oral medication and steroid injection. FlowerAmnioFlo Allograft Injection (CPT 20610/RT, 20610/LT, 77002 x2, Q4177 x2) 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve FlowerAmnioFlo Allograft Injection (CPT 20610/RT, 20610/LT, 77002 x2, Q4177 x2), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller harness (E2313), expandable 
controller (E2377) and an electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller harness, expandable controller and electronic 
connection. You say that you would like reconsideration because these supplies are medically necessary. The 
Plan denied your request. The Plan says there is not a medical need to control these power options through the 
joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller harness (E2313), expandable 
controller (E2377) and an electronic connection (E2311).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to IRF 
following treatment for bleeding in the brain. The enrollee has been in an IRF since 8/17/20 after suffering a 
stroke (IPH in the right cerebellar region). Small PICA dissection was noted on angiogram. She is on a 
dysphagia diet. Aspiration precautions are in place. She is now hemodynamically stable. She is limited by 
fatigue and is mostly moderate assist for activities of daily living and transfers.  
 
The enrollee is now mostly moderate assist for all care.  The enrollee has no complex wound care needs, or IV 
medication requirements.  There are no nursing or therapy needs that are skilled, and warranting a SNF as 
opposed to a lesser level of care.  The enrollee's vital signs are stable; SNF is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 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 you are generally medically stable with no recent neurological or Orthopedic events 
and there is no evidence of complex medical issues that require monitoring by an inpatient Physical Medicine 
and Rehabilitation (PMR) physician three times per week or need for acute rehab nursing care. Currently you 
still require physical therapy (PT) and occupational therapy (OT). While you may benefit from continuing PT 
and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with 
frequent physician oversight and an interdisciplinary approach to rehabilitation care. Based on review of the 
available records, you not meet Medicare coverage criteria for an admission to an IRF. Admission to an IRF is 
not medically necessary based on lack of medical complexity and current functional status. 
 
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.