Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at a different level of 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 reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that based on the medical records provided, the complexity of the enrollees nursing, medical and 
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The physician has documented that the enrollee will tolerate, and is expected to benefit from, 3 hours of 
therapy daily in an intensive rehabilitation therapy program. An acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care is medically reasonable and necessary for the enrollee 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 bilateral lower limb prostheses.
You asked the Plan to pre-approve a bilateral lower limb prostheses. You say that the requested prostheses is
medically necessary. The Plan denied your request. The Plan says the requested prostheses is not medically
reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that information must be submitted by the supplier or
provider to corroborate the documentation in the beneficiary's medical documentation and confirm that
Medicare coverage criteria have been met.
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 bilateral lower limb prostheses. Our
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has a history of heart disease, diabetes, hypertension, and kidney disease,
who underwent bilateral transtibial amputations due to vascular disease. It is documented that the enrollee
received bilateral prosthetic legs from the clinic in June, 2019. The enrollee underwent an initial evaluation at a
prosthetic and orthotic institute on March 27, 2020. It is stated that the enrollee received the right prosthesis 4
years ago. Problems with the prosthesis are documented. A new prosthesis was ordered to improve
independence in mobility related activities of daily living, and to avoid falls and skin breakdown. A letter from
the prosthetic and orthotic institute dated July 27, 2020 documents that the left prosthesis is 3 1/2 years old. and
the right prosthesis is over 4 years old. The case file does not contain an evaluation of the prostheses that were
dispensed in 2019. Without this necessary information, medical necessity has not been substantiated.
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 bilateral lower limb prostheses have not been met. Therefore, we decided that
the Plan does not have to pre-approve a bilateral lower limb prostheses.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in 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: Unfavorable

 
We decided that the Plan does not have to pre-approve Clorazepate 7.5mg tablet 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 Medicare says Part B programs can only provide limited benefits for 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 Clorazepate 7.5mg tablet 
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left radiofrequency ablation of the lumbar medical 
branch blocks. 
 
You asked the Plan to pre-approve left radiofrequency ablation of the lumbar medical branch blocks. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation of the lumbar medical branch 
blocks are only covered for certain 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 left radiofrequency ablation of the 
lumbar medical branch blocks. Our reviewer says that the documentation does not support that the requested 
services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low 
back pain. The enrollee had only one set of diagnostic bilateral medical branch blocks which provided 80% 
pain relief. The LCD requires DUAL diagnostic medical branch blocks which produce greater than 80% pain 
relief. Since only one set of diagnostic blocks were performed, the request is deemed not 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 left radiofrequency ablation of the lumbar medical branch blocks have not been 
met. Therefore, we decided that the Plan does not have to pre-approve left radiofrequency ablation of the 
lumbar medical branch blocks.
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 you would like to participate in therapy to be 
able to go home. The Plan denied your request. The Plan says that you do not require skilled nursing care as 
defined by Medicare rules. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional LogistiCare mileage.
You asked the Plan to pre-approve additional LogistiCare mileage. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says you are only covered for up to 50 miles
per one-way trip.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 60 one-way transportation trips per year, not to exceed 50 miles per one-way
trip.
We looked at your request, the records in the case file, and the rules. The request is for transportation at 104
miles per one-way trip. The Plan contract clearly says you are only covered for up to 50 miles per one-way trip.
Therefore, we decided that the Plan does not have to pre-approve additional LogistiCare mileage.
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 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 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 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 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Although the record supports the need for physical and 
occupational therapy services, it does not support a need for intensive rehabilitation services. The needed 
services can be provided in a different level of 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. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network pain management specialists 
available to you that can provide the care and treatment you are requesting. 
 
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 
the physician services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IV Feraheme. 
 
You asked the Plan to pre-approve the IV Feraheme. You say that you would like reconsideration because the 
member has had iron deficiency for 6 months. The Plan denied your request. The Plan says the member has not 
tried oral iron supplements. 
 
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 IV Feraheme. Our reviewer says 
that the member does not have a history of chronic kidney disease (CKD). There is no documentation that she 
has taken oral iron supplements without improvement of hemoglobin/hematocrit (H/H) levels, nor that she was 
intolerant of oral supplements. Our physician reviewer found the documentation does not support that the 
Feraheme is medically reasonable and necessary for the member. The documentation does not support that the 
Feraheme is safe and effective for the member. 
 
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 IV Feraheme have not been met. Therefore, we decided that the Plan does 
not have to pre-approve IV Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection services. 
 
You asked the Plan to pre-approve sacroiliac joint injection services. You say that the records provided support 
the need for the requested injection services. The Plan denied your request. The Plan says research has not 
proven that the requested service is helpful. The Plan says that it is considered experimental and 
investigational. The Plan says that the records do not show that the enrollee has had three or more positive test 
results to support the requested injection services. 
 
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 sacroiliac joint injection services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has chronic low back pain and has been receiving SI joint injections 
with varying degrees of pain relief. In some progress notes, 3 SI joint tests are detailed but not in others. There 
is one progress note that details physical therapy not having been beneficial. There Is no record of recent 
conservative therapy, including an NSAID trial or a reason why it would be contra-indicated. The enrollee has 
been receiving Monitored Anesthesia Care (MAC) during the SI joint injections. There is no indication for 
MAC in this enrollee, as she does not have any unstable medication condition, morbid obesity, or psychiatric 
illness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that the device is an essential part of the 
enrollee's long-term effective home treatment. The Plan denied your request. The Plan says there is no 
documentation of a 4-week trial of a basic pump. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device is only covered 
under certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested device. Our physician 
reviewer found that the enrollee has a past medical history of diabetes and hypertension, who also has 
hereditary lymphedema of both lower extremities. She trialed and failed a basic pneumatic compressive device 
only on a one-time basis. There is no documentation that the enrollee tried and failed a 4-week trial of a basic 
pump. Therefore, the requested device is not medically reasonable and necessary to treat 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an advanced pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous and/or interlaminar device. 
 
You asked the Plan to pre-approve interspinous and/or interlaminar device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 interspinous and/or interlaminar device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has low back pain secondary to lumbar spinal stenosis. 
The requested device is considered experimental for use in the spine. More research is needed to show safety 
and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 interspinous and/or interlaminar device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve interspinous and/or interlaminar device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix for the enrollee. 
 
You asked the Plan to pre-approve Nulojix. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the enrollee does not meet coverage criteria for Nujolix. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Nulojix. Our reviewer says that Nulojix 
is not medically reasonable and necessary for the enrollee in this case. In this case, the requested use of Nulojix 
is not FDA-approved for the enrollee's diagnosis. Its use in this case is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for coverage of Nujolix. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nulojix for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aloxi for the enrollee. 
 
You asked the Plan to pre-approve Aloxi. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the use is not medically necessary in this case. 
 
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 Aloxi. Our reviewer says that Aloxi is 
not medically reasonable and necessary for the enrollee in this case. The enrollee has recurrent metastatic 
endometrial cancer. Aloxi is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is 
not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of Aloxi. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Aloxi for the enrollee.