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

 
We decided that the Plan has to pre-approve the CT, abdomen; without contrast material, followed by contrast 
material(s) and further sections (CPT Code 74170). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has unspecified abdominal pain. The 
Plan denied your request. The Plan says that the clinical information provided does not describe results of an 
esophagogastroduodenoscopy (EGD). 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plan's contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on no medical necessity. 
Therefore, we decided that the Plan has to pre-approve the CT, abdomen; without contrast material, followed 
by contrast material(s) and further sections (CPT Code 74170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an oral sleep appliance. You say that you would like approval for this 
equipment. The Plan denied your request. The Plan says there are 9 in-network providers within a 50-mile 
radius of the member's zip code. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you need this because you don't have 
support standing up. The Plan denied your request. The Plan says the record does not show you are completely 
unable to stand from any chairs in your home. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if the enrollee is 
completely unable to stand up from a regular armchair or any chair in the home. 
 
We looked at the file and Medicare rules. The submitted documentation indicates that you are not completely 
incapable of standing up from any chair in your home. Based on this information, we decided that Medicare 
rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism (E0627).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there is no skilled nursing need and function is at baseline. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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 do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a re-evaluation of a physical therapy established plan of 
care. 
 
You asked the Plan to pre-approve the evaluation. You say that this is medically necessary. The Plan denied 
your request. The Plan says the unique and sophisticated skills of a physical therapist are not required to 
continue to treat your condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 evaluation. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for your condition. you have had prior therapy per documentation but the documentation does 
not indicate you require the unique skills of a professional therapist to safely and effectively provide ongoing 
treatment. The services do not need to safely and effectively be performed only by a therapist, or under the 
supervision of a therapist. The documentation does not reveal significant measurable progress from prior 
therapy or specific indications of what manual treatment is being performed. The requested services are not 
part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. 
 
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 evaluation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a re-evaluation of a physical therapy established plan of care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions. 
 
You asked the Plan to pre-approve the extractions. You say that the enrollee has been advised to have his teeth 
extracted immediately to prevent infections. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's benefit plan. 
 
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 
dental extractions.
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 LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says you can receive same services at the current level of 
care. 
 
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 does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar Vertiflex interspinous spacer. 
 
You asked the Plan to pre-approve a lumbar Vertiflex interspinous spacer. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 lumbar Vertiflex interspinous spacer. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the spacer remains experimental. More research is needed to show 
safety and efficacy of the device. 
 
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 Vertiflex interspinous spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar Vertiflex interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital admission. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that the services are 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 inpatient hospital admission. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have 3 lumbar spine fractures. It is stated that a fracture of the lumbar spine 
would qualify for admission. Admission is indicated and reasonable and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio Blood Glucose/Reagent Strips 
(A4253). 
 
You asked the Plan to pre-approve OneTouch Verio Blood Glucose/Reagent Strips. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not a preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested test strips are not from the Plan?s preferred brands. No 
medical reasoning is given as to why the enrollee cannot use a preferred brand. Based on this information, we 
decided that Medicare rules for coverage of OneTouch Verio Blood Glucose/Reagent Strips have not been met. 
Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio Blood Glucose/Reagent 
Strips (A4253).
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require treatment 
by multiple therapies, including either physical therapy or occupational therapy, but you do not require skilled 
nursing care or a multi-disciplinary approach. You have been medically stable with a poor appetite. You are 
tolerating an oral diet. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says they did not receive documentation supporting the medical 
necessity for a step therapy exception. 
 
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 Synvisc-One (J7325). Our reviewer 
says that the drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Synvisc-One is not approved as 
step 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 Synvisc-One (J7325) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. 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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc.  Step therapy, as outlined by the Plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered or that the plan's required drugs would likely be less effective or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab/Imfinzi 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 based on the information about the enrollee's condition, the enrollee does not meet all of 
the requirements. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Durvalumab is FDA 
approved for the treatment of unresectable stage III non-small cell lung cancer in adults whose disease has not 
progressed following concurrent platinum-based chemotherapy and radiation therapy. There are no off-label 
uses supported by major drug compendia. For consolidative therapy without prior platinum based therapy there 
is no support in the medical literature. The service is not reasonable or 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durvalumab/Imfinzi for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi solution 500mg/10ml 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 previous treatment has not been received from small cell lung cancer. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the indication and 
compendium supported uses for Imfinzi in small cell lung cancer are for extensive disease as part of initial 
therapy. The requested use is to have the drug begin after initial therapy to be used for maintenance for non-
extensive disease. The NCCN Guideline Version 1.2021 Small Cell Lung Cancer defines extensive stage as 
stage IV (T any, N any, M 1a/b/c or T3-4 not able to be encompassed in a tolerable radiation plan. Therefore, 
the requested use is not medically reasonable and necessary for the enrollee. The requested use is not safe and 
effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Imfinzi solution 500mg/10ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone packets for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered 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 Testosterone packets for the 
enrollee.