Persius/hicric huggingface dataset:
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 based on review of available records, you do not meet Medicare criteria for coverage 
for an IRF admission. You are generally medically stable with Debility and Polyneuropathy 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 (3) times per week or need for 
acute rehab nursing care. Currently you still require no physical therapy (PT) and occupational therapy (OT) as 
you have paid health aide. 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. 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.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the upper extremity 
(73221). 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
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. No medical records were provided to the IRE for review. Several requests were 
made and the plan has not provided any clinical documentation to the IRE. Therefore, we decided that the Plan 
has to pre-approve magnetic resonance imaging (MRI) of the upper extremity (73221).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that this should be covered 
because the warranty on your current device has expired and Medicare has paid for power wheelchairs in the 
past. The Plan denied your request. The Plan says this was not ordered by your doctor and is not shown to be 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to irreparable 
wear takes into consideration the reasonable useful lifetime of the equipment, which cannot be less than 5 
years.  Replacement may be reimbursed when a new physician order and/or new CMN, when required, is 
needed to reaffirm the medical necessity of the item. The rules also say that, Power Mobility Devices (PMDs) 
require a standard written order prior to delivery (WOPD), which may only be written after the completion of 
the face-to-face encounter requirements. 
 
We looked at the file and Medicare rules. The documentation does not show that a physician order has been 
placed for this item. The submitted medical records do not show that you have mobility limitations that meet 
criteria for a power wheelchair. The documentation also does not contain information on your current 
wheelchair such as when it was provided, therefore it cannot be verified whether it is eligible for replacement. 
Based on this information, we decided that Medicare rules for coverage of a replacement power wheelchair 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement power 
wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an amyloid PET scan. 
 
You asked the Plan to pre-approve an amyloid PET scan. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says an amyloid PET is not covered in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare says the evidence is insufficient to conclude that the use of 
positron emission tomography (PET) scan beta amyloid imaging is reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member for enrollee's with 
dementia or neurodegenerative disease, and thus PET amyloid-beta imaging is not covered. There is also no 
documentation showing that the enrollee is involved in a clinical research study. Based on this information, we 
decided that Medicare rules for coverage of an amyloid PET scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an amyloid PET scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan 550mg tablets. 
 
You asked the Plan to pre-approve the Xifaxan tablets. You say that this medication is necessary. The Plan 
denied your request. The Plan says this self-administered drug cannot be covered by Medicare 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 Xifaxan 550mg tablets.  
 
Benefits for the Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee 
osteoarthritis. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Synvisc One is not 
reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services 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 Testosterone. 
 
You asked the Plan to pre-approve Testosterone. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B 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 Testosterone.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan (J7321). 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 Orthovisc and Monovisc 
 
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 Hyalgan (J7321). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found criteria for Hyalgan is 
not met. There is no documentation of failure or contraindication to first line medications such as Monovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan (J7321) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the porcelain/ceramic pontic and porcelain/ceramic 
retainer crowns. 
 
You asked the Plan to pre-approve the porcelain/ceramic pontic and porcelain/ceramic retainer crowns. You 
say that you do not agree with the denial. You say that at least the crown should be covered. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
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 
porcelain/ceramic pontic and porcelain/ceramic retainer crowns.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gastrointestinal Tract Imaging Intraluminal. 
 
You asked the Plan to pre-approve the Gastrointestinal Tract Imaging Intraluminal. You say that you would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the reason for 
this test does not meet any criteria for medical necessity. 
 
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 Gastrointestinal Tract Imaging 
Intraluminal. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the member meets none of the provided coverage criteria. 
From the perspective of community-accepted indications, the member does not have GI bleeding, known or 
suspected Crohn's disease, nor radiographic demonstration of a small bowel tumor. Further, the member is at 
risk for impaction of the ingested wireless capsule within his small bowel. Such a scenario might then require 
emergency bowel resection with associated and unnecessary risk of morbidity and mortality. 
 
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 Gastrointestinal Tract Imaging Intraluminal have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Gastrointestinal Tract Imaging Intraluminal.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Saxenda Pen.
You asked the Plan to pre-approve Saxenda Pen (J3490). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 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 Saxenda Pen.
Benefits for Saxenda Pen (J3490) 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 a crown for tooth #3 (D2790), periodontal scaling and root planing for the upper left quadrant and lower right quadrant (D4341) and surgical extraction for tooth #29 (D7210).
You asked the Plan to pre-approve the crown, periodontal scaling and root planing and extractions.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the criteria for coverage of these services have 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 the crown, periodontal scaling and root planing and extractions.. Our reviewer says that the documentation is insufficient to demonstrate that removal of bone and/or sectioning of tooth is required for the enrollee in this case. Our physician reviewer found the submitted images are insufficient to demonstrate root surface calculus or noticeable loss of bone support to indicate periodontal scaling and root planing. Additionally, submitted imaging does not show the required pathologic destruction to support coverage of the requested crown.
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 crown, periodontal scaling and root planing and extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #3 (D2790), periodontal scaling and root planing for the upper left quadrant and lower right quadrant (D4341) and surgical extraction for tooth #29 (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity orthoses (CPT Code L2999), for the 
enrollee. 
 
You asked the Plan to pre-approve lower extremity orthoses. You say that this is medically necessary. The Plan 
denied your request. The Plan says this would exceed the enrollee's needs 
 
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 lower extremity orthoses. Our physician 
reviewer found the patient appears to require knee extension assist in the absence of any co-existing joint 
contracture and ankle plantar flexion assist in the absence of any co-existing joint contracture. The requested 
item appears to exceed the patient's medical needs. There is no evidence that an appropriately fitted standard 
(non-computer stance controlled) is unable to meet the patient's functional needs. Furthermore, there are 
limited large studies in the peer reviewed literature indicating that the requested E-Mag Control system is 
effective and safe for this patient's condition and furnished in accordance with accepted standards of medical 
practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body 
member. The requested item exceeds the patient's medical and functional needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity orthoses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lower extremity orthoses (CPT Code L2999), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Behavioral Health Inpatient services. 
 
You asked the Plan to pre-approve Behavioral Health Inpatient services. You say that Behavioral Health 
Inpatient services are medically  necessary. The Plan denied your request. The Plan says outpatient services are 
recommended. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 Behavioral Health Inpatient services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon review 
the records provided it was not expected this enrollee would improve in a reasonable period of time as the 
enrollee did not have dangerousness to self or others and was not showing any delusions or auditory/visual 
hallucinations while not showing any aggressive behaviors. The enrollee was noted to be cooperative. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care. The health plan's denial of inpatient psychiatric services appears appropriate. 
It did not appear that active treatment was taking place. It did not appear that the services were reasonably 
expected to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an 
individualized treatment plan however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review the records provided for the admission of this 
enrollee does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a 
danger to herself or others, no auditory or visual hallucinations. The enrollee is noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Behavioral Health Inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Behavioral Health Inpatient services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health occupational therapy services. 
 
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says the visit notes do 
not delineate deficits in daily living tasks or specify skills for the occupational therapy visits to restore function. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that no recent medical records show that skilled therapy services are currently required to effectively 
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or to prevent deterioration. Our physician reviewer 
found the records provided do not support that the home health services requested are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health occupational therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limb compression device (E0676). 
 
You asked the Plan to pre-approve a limb compression device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that a Pneumatic Compression Devices (PCD) 
that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) 
is a preventive service. Items that are used for a preventative service or function are excluded from coverage 
under the Medicare DME benefit. 
 
We looked at the file and Medicare rules. The requested device is considered preventative and is not covered. 
Based on this information, we decided that Medicare rules for coverage of a limb compression device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a limb compression device 
(E0676).