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

We decided that the Plan does not have to pre-approve transfer from one skilled nursing facility (SNF) to 
another facility for continued SNF services. 
 
You asked the Plan to pre-approve transfer from one SNF to another facility for continued SNF services. You 
say that the requested transfer from one SNF to another facility for continued SNF services is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for transfer from one 
SNF to another facility for continued SNF services. 
 
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 transfer from one SNF to another 
facility for continued SNF services. Our reviewer says that daily skilled services are not necessary. Our 
physician reviewer found the enrollee is with right hip fracture admitted to the SNF. From a nursing 
perspective, the enrollee received oral medications.  The enrollee had stable vital signs. She was treated for 
pain with effect.  Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy 
and occupational therapy in the SNF.  By the dates in question, the enrollee was at a stand by assist to contact 
guard assist level with functional mobility including gait to 140 feet with a rolling walker.   
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 transfer from one SNF to another facility for continued SNF services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve transfer from one skilled nursing 
facility (SNF) to another facility for continued SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the pelvis with and without dye. 
 
You asked the Plan to pre-approve an MRI of the pelvis with and without dye. You say that the requested MRI 
of the pelvis with and without dye is medically necessary. The Plan denied your request. The Plan says the 
requested MRI of the pelvis with and without dye is not medically 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 of the pelvis with and without 
dye. Our reviewer says that the requested MRI of the pelvis with and without dye is not medically necessary. 
Our physician reviewer found the enrollee is with urinary retention due to an enlarged prostate. Treatment with 
tamsulosin has been effective. PSA was 2.0 ng/mL in 2020 which was essentially unchanged from 1.98 ng/mL 
in 2013. Request is for coverage of MRI of the pelvis with and without contrast. The MRI of the pelvis with 
and without contrast is not medically reasonable and necessary. 
 
According to the Joint Consensus Statement of the American Urological Association (AUA) and Society of 
Abdominal Radiology (SAR) 'when high-quality prostate MRI is available, it should be strongly considered in 
any patient with a prior negative biopsy who has persistent clinical suspicion for prostate cancer and who is 
undergoing a repeat biopsy.'
 
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 of the pelvis with and without dye have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an MRI of the pelvis with and without dye.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulation. 
 
You asked the Plan to pre-approve deep brain stimulation. You say that deep brain stimulation is medically 
necessary for intractable dystonia. The Plan denied your request. The Plan says the enrollee does not have a 
covered indication for the requested service. 
 
The Plan follows Medicare rules. Medicare rules say that deep brain stimulation is only covered under certain 
medical indications. 
 
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 deep brain stimulation. Our physician 
reviewer found that coverage for the services are limited to essential tremor (ET) and/or Parkinsonian tremor. 
The enrollee in this case does not have either of these conditions.  
 
 
While it is noted that the FDA has previously approved the use of DBS for "unilateral or bilateral 
stimulation of the internal globus pallidus or subthalamic nucleus to aid in the management of chronic, 
intractable (drug refractory) primary dystonia", the medical records provided indicate that the enrollee in this 
case has secondary dystonia due to a combination of conditions. The literature on the use of DBS in secondary 
dystonia has not shown there to be a consistent and beneficial response from the use of the proposed therapy. 
Further research is needed to establish the long-term efficacy and safety of DBS of the internal globus pallidus 
nucleus. In this setting, it cannot be concluded that the proposed course of treatment would be safe and 
effective for the enrollee's condition. In as much, this service cannot be said to be 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 deep brain stimulation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve deep brain stimulation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta (J8499). 
 
You asked the Plan to pre-approve Nuedexta. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Nuedexta (J8499).  
 
Benefits for Nuedexta 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: Favorable

We decided that the Plan has to pre-approve Hydromorphone compound (J1170). 
 
You asked the Plan to pre-approve Hydromorphone compound. You say that the medication is necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 Hydromorphone compound. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found Hydromorphone intra-thecal is part of a standard authoritative clinical practice 
guideline for intra-thecal therapy. The requested medication is 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 Hydromorphone compound have been met. Therefore, we decided that the Plan 
has to pre-approve Hydromorphone compound (J1170).  
 
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 Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been 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 Entyvio. Our reviewer says that the 
criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of 
Stelara before they will approve the requested drug. Based on the medical records provided there is no 
indication that the patient has tried Stelara or that Stelara would likely be less effective or have adverse effects 
for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used 49 of the 50 allotted trips 
and only have one trip remaining for the 2020 benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 49 of 
the 50 allotted trips and you only have one trip remaining for the 2020 benefit year. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are requesting 
review of denial of services. The Plan denied your request. The Plan says you utilized nineteen (19) one-way 
trips and have five (5) remaining. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 25th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve 24 additional 
routine transportation trips.
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 this is medically necessary. The Plan denied your 
request. The Plan says you could be treated at a lower level of care. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the records do not show that you require 
skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not 
have complex wound care or other ongoing skilled nursing needs. Your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist  to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. 
 
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: 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 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 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says continued 
SNF care 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 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require 
ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 
the last covered date.  The enrollee does not have complex wound care or other ongoing SNF level skilled 
nursing needs. The enrollee's functional level with current weight bearing restrictions does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The 
enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" in a SNF beyond the last covered date. As a practical matter, this enrollee does not require the 
necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary upper denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary upper denture (D5110). You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says you were provided immediate 
maxillary (upper) dentures on July 12, 2017, which is less than 5 years ago. 
 
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 complete maxillary 
(upper) denture is not covered at this time as the file shows you received an immediate maxillary (upper) 
denture on July 12, 2017, which is less than 5 years ago. Therefore, we decided that the Plan does not have to 
pre-approve a complete maxillary upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz injection. 
 
You asked the Plan to pre-approve the requested injection. The Plan denied your request. The Plan says the 
enrollee has not tried and failed conservative treatment. 
 
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 requested injection. Our physician 
reviewer found that the enrollee has left knee pain. The arthrogram showed joint space narrowing, osteophytes, 
and was consistent with osteoarthritis of the knee. Current treatment includes Tylenol. Based upon the 
submitted records the requested procedure 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 requested injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Supartz injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coolief radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. You say that radiofrequency ablation achieved a 
greater degree and longer duration of pain relief for osteoarthritis of the knee. The Plan denied your request. 
The Plan says there is not enough information that shows the requested service works long term. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic right knee pain. He is taking Diclofenac, Gabapentin, and Norco 
for pain. He has had a trial of physical therapy. The request is for cooled radiofrequency ablation of the right 
genicular nerves. This is considered an experimental/investigational procedure that is the subject of on-going 
clinical trials. Therefore, the request is considered 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Coolief radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Olanzapine. 
 
You asked the Plan to pre-approve Olanzapine. You say that the enrollee has been stable on this medication. 
The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under Part B. 
 
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 Olanzapine.  
 
Benefits for Olanzapine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levothyroxine 50 MCG Tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this drug is not covered for the enrollee's condition by their 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 Levothyroxine 50 MCG 
Tablet.  
 
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.