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

 
We decided that the Plan does not have to pre-approve Saxenda. 
 
You asked the Plan to pre-approve Saxenda. You say that Saxenda is an essential part of the enrollee's 
medication regimen. The Plan denied your request. The Plan says this 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 Saxenda.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (Aflibercept). 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee's left eye doesn't function at all. The Plan 
denied your request. The Plan says the enrollee has not had prior therapy, or cannot use Bevacizumab. 
 
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 Eylea. Our physician reviewer found 
that the enrollee has a diagnosis of Exudative age-related macular degeneration, right eye, with active choroidal 
neovascularization. The vision in the enrollee's right eye is 20/25 - 1. The Plan requires a trial of Bevacizumab 
before they will approve the requested drug. The documentation does not show that the enrollee has tried and 
failed the required drug. The documentation does not sufficiently support that Bevacizumab would likely be 
less effective, or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (Aflibercept).
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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally medically stable and the 
documentation does not support that she has complex medical issues that require acute rehab nursing care, or 
monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee is 
reasonably expected to benefit from continued physical therapy (PT) and occupational therapy (OT), the 
documentation does not support that there is need for an intensive therapy program with therapy 3 hours per 
day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide this service. Therefore, coverage criteria has not been met. 
 
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 
a magnetic resonance imaging (MRI) of the lumbar spine (72148) to be provided by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequecy neurolysis (64635). 
 
You asked the Plan to pre-approve radiofrequecy neurolysis. You say that the enrollee had a positive response 
to a medical branch block. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the destruction of cervical, thoracic or lumbar 
paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary 
according to the guidelines listed 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 radiofrequecy neurolysis. Our reviewer 
says that the requested radiofrequecy neurolysis is medically necessary.  
Our physician reviewer found the records show that paravertebral facet joints have been identified as the source 
of the patient?s pain and patient failed conservative treatment. The patient meets the criteria for coverage of this 
service and none of the limitations apply. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequecy neurolysis have been met. Therefore, we decided that the Plan 
has to pre-approve radiofrequecy neurolysis (64635).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
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 skilled nursing services would be more appropriate for your condition. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted because of a series of falls. You 
have ulcers on your legs that require daily dressing changes. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The record does 
support a need for physical and occupational therapy but there is no need for an intensive rehabilitation 
program. 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 IRF. Our physician reviewer found that your 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.
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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally medically stable and the 
documentation does not support that she has complex medical issues that require acute rehab nursing care, or 
monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee is 
likely to benefit from continuing physical therapy (PT) and occupational therapy (OT), the documentation does 
not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that 
your 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a consultation to be provided by on OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide this care. Therefore, coverage criteria has not been met. 
 
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 
a consultation to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (D3310), bone 
replacement graft for ridge preservation (D7953), prefabricated post and core in addition to crown (D2954), 
core buildup, including any pins when required (D2950), retainer crown - porcelain/ceramic (D6740), surgical 
placement of implant body: endosteal implant (D6010), second stage implant surgery (D6011) and custom 
fabricated abutment - includes placement (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary to obtain a better 
quality of life. The Plan denied your request. The Plan says the services are not a covered benefit under the 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy, anterior tooth (D3310), bone replacement graft for ridge preservation (D7953), prefabricated post and 
core in addition to crown (D2954), core buildup, including any pins when required (D2950), retainer crown - 
porcelain/ceramic (D6740), surgical placement of implant body: endosteal implant (D6010), second stage 
implant surgery (D6011) and custom fabricated abutment - includes placement (D6057).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. 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 inpatient psychiatric care. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of August 28, 2020 forward 
and could have been treated in a lesser restrictive setting. He was not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. He was 
being cooperative and compliant and able to perform activities of daily living (ADL?s) while not showing any 
acute threats to safety. 
 
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 psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of a CardioMEMS device (33289, 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS placement. You say that the device is medically necessary 
and will reduce hospitalizations. The Plan denied your request. The Plan says there is insufficient data to 
support that the device would be beneficial for the enrollee. 
 
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 CardioMEMS placement. Our 
reviewer says that the requested procedure is not medically necessary. Our physician reviewer found therapy 
change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help 
reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about 
potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is 
uncertain at this time according to leading authorities and not recommended in current guidelines for the 
treatment of heart failure. Medicare coverage criteria are not met since the device is still considered 
experimental or investigational. 
 
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 CardioMEMS placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the placement of a CardioMEMS device (33289, C2624).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
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 Prolia. Our reviewer says that the 
case file does not support that Zoledronic acid has been tried and failed. Our physician reviewer found the 
documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have 
adverse effects. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
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 the documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are 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. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition 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 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) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to stay in a SNF longer. The Plan 
denied your request. The Plan says that your needs can be safely and better managed in a less restrictive setting. 
 
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the abdomen, pelvis and thorax. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a repeat scan is not considered medically necessary at this time, as no new evidence of 
recurrence has been documented. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found while there are no 
formal reports for the aforementioned PET/CT and CT scans the referring oncologist, the doctor suggested on 
7/6/20 that you return to clinic one year from his visit without any mention or reason for CT of the chest, 
abdomen and pelvis in light of the negative PET/CT of 6/3/20 referenced in his note. Absent any clinical 
evidence of recurrence, the negative PET/CT of 6/3/20 and without any rationale given for CT of the chest, 
abdomen and pelvis at this time the medical necessity of the requested scans has not been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the abdomen, pelvis and thorax.