Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan injections. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs injections to both 
knees to improve his functional status. The Plan denied your request. The Plan says the enrollee has not tried 
Euflexxa, Synvisc, and Synvisc-One. 
 
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 requested services. Our physician 
reviewer found that the Plan requires a trial of Euflexxa, Synvisc, and Synvisc-One before they will approve 
the requested drug. The enrollee has not tried and failed the plan-required drugs. The documentation does not 
outline contraindications or reasons these medications were not considered. Therefore, Hyalgan is not 
considered medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyalgan injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Acetaminophen-Codeine. 
 
You asked the Plan to pre-approve Acetaminophen-Codeine. You say that the enrollee has been taking over the 
counter pain relievers with minimal relief. The Plan denied your request. The Plan says the drug is not covered 
for the enrollee's condition by the 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 Acetaminophen-Codeine.  
 
Benefits for Acetaminophen-Codeine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have a need for physician supervision and a multidisciplinary team for care. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for elective lumbar spinal surgery to treat spinal 
stenosis. Medical problems are stable. The complexity of the enrollee's nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. The medical record supports a need for physical 
and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Xofigo. 
 
You asked the Plan to pre-approve Xofigo. You say that the requested drug is used to treat prostate cancer that 
no longer responds to hormonal or surgical treatment that lowers testosterone. The Plan denied your request. 
The Plan says that Xofigo in combination with other agents is considered unproven. 
 
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 Xofigo. Our physician reviewer found 
that the request is for Xofigo to treat bone metastases from castration resistant prostate cancer with a rising 
PSA, worsening bone scan, no visceral metastases and requiring Oxycodone/Acetaminophen for pain. The 
enrollee continues to be treated with androgen deprivation therapy, Lupron, and has progressed on Lupron, 
Casodex, Zytiga and Xtandi. Per the FDA website, Xofigo is indicated for the treatment of patients with 
castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. 
The documentation supports that Xofigo is safe and effective and is medically reasonable and necessary 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 Xofigo have been met. Therefore, we decided that the Plan has to pre-approve 
Xofigo.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional six (6) OT visits. 
 
You asked the Plan to pre-approve OT visits. You say that you need more therapy on your left arm as you are 
unable to move it completely. The Plan denied your request. The Plan says ongoing OT is not reasonable and 
necessary as there must be an expectation that the condition will improve significantly in a reasonable and 
generally predictable period of time based on the physician's assessment of the patient's rehabilitation potential, 
after any needed consultation with the qualified physical therapist. 
 
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 OT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found based on the medical records provided there is no documentation that the 
additional six therapy visits are generally accepted as specific and effective therapy for your condition. You 
have received twenty treatments and appear to have plateaued; two additional visits to transition to a home 
exercise program are needed but the denied six visits are not necessary. There is no documentation that the 
additional six therapy visits require the unique skills of a professional therapist.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional six (6) OT visits.
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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee was admitted to the acute inpatient setting for treatment of seizure 
disorder and respiratory failure requiring intubation with ventilator support. The documentation does not 
support that the enrollee requires services at the LTACH that are not available at the acute care hospital where 
the enrollee is 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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says you do 
not have a covered indication, and are not on maximal medication management. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are 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 the requested service. Our physician 
reviewer found that you have chronic back pain, and a syrinx in the thoracic spine. You are taking Ibuprofen, 
Gabapentin, Tizanidine and Topiramate for pain. You underwent a psychological examination, and were found 
to be an acceptable candidate for spinal cord stimulation. However, you do not have an evidence based 
indication for the requested service. You also have not had several of the other evidence based available 
therapies. Therefore, the requested procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says there is no 
documentation of an in-person visit to assess the treatment plan. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. In this case, there is insufficient records to show that the coverage 
criteria have been met for the requested monitor. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor beyond what has been approved by the Plan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair. 
 
You asked the Plan to pre-approve a wheelchair. You say that the cane and walker are no longer sufficient for 
the enrollee's needs. The Plan denied your request. The Plan says the documentation does not show that the 
enrollee's home can fit the wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchair are 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 a wheelchair. Our physician reviewer 
found that the enrollee has a personal mobility deficit, but the documentation is not clear that it specifically 
impairs participation in MRADLs. She is currently ambulating with a cane, but has difficulty walking over 6 
feet with exertion.  
The documentation does not reveal a trial of a wheelchair, but the provider states the enrollee can safely use the 
device. The documentation does not reveal an objective home assessment indicating her home provides 
adequate access between rooms, maneuvering space, and surfaces for use of the requested  manual wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show non-restorable teeth. 
 
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. The Plan covers the surgery 
when the services are medically necessary and reasonable.  
 
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 surgery. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found it appears the 
enrollee does not have any restorable teeth and dentures have been treatment planned. Medicare does not 
provide for treatment of the teeth and supporting structures, and only allows treatment of the teeth where it is 
secondary to a primary medical procedure.  In this instance, the extraction of the teeth is the primary procedure, 
and falls under the exclusions of the Medicare statute in section 140 - Dental Services Exclusions. Given these 
provisions, the policy can not support coverage for the requested dental extractions and related services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental surgery for the enrollee.
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 you are in intense pain and need proper care. The 
Plan denied your request. The Plan says your care is not complex, and there is no need for a team of providers. 
 
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 physician reviewer found 
that you are at a maximal assist level for bed mobility, transfers, and ambulation using a rolling walker. You do 
not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours 
per week of rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF 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 complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted after transient loss of consciousness 
and a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. You say that the enrollee has been stable on the current medication 
regimen. The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription 
drugs. 
 
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 Xarelto.  
 
Benefits for Xarelto 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device. 
 
You asked the Plan to pre-approve Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
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 Vertiflex device. Our reviewer says that 
the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with 
chronic low back pain into the left buttock/hip area, limiting walking and standing for long periods. The 
requested Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 your do not have an identified need for skilled services on a daily basis. 
 
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 your condition does not meet 
Medicare criteria for SNF services. 
 
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.
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 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 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 enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be at a 
new level of function following his stroke in August. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this 
point are custodial and, as a practical matter, can be provided at a lower level of 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.