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

 
We decided that the Plan does not have to pre-approve Supartz FX injections (J7321). 
 
You asked the Plan to pre-approve Supartz FX. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be 
considered. 
 
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 Supartz FX. Our reviewer says that the 
requested Supartz FX is not medically necessary. Our physician reviewer found the record shows no trial of the 
plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for this 
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 Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX injections (J7321).
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 the medical records, you do not meet the Medicare coverage 
criteria for an IRF admission. You are generally medically stable after a with cardiac Debility with no evidence 
of medical or nursing needs for an IRF. You need physical therapy (PT) and occupational therapy (OT) bit not 
in an IRF. Your current functional status does not require IRF level of therapies. There is no evidence of 
medical issues that require monitoring by an inpatient rehab physician three (3) times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. The IRF admission is not medically necessary and also does not meet 
the Medicare coverage criteria. Your rehab needs can be safely and effectively met in an alternate, less intense 
setting such as in a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Emgality. 
 
You asked the Plan to pre-approve Emgality. The Plan denied your request. The Plan says the drug is not 
covered for the enrollee's condition 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 Emgality.  
 
Benefits for Emgality 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 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 review has determined that you do not require services at the LTACH that are not 
available at the acute care hospital where you are currently receiving care. There are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and 
condition and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine transportation trips.You asked the Plan to pre-approveroutine transportation trips. The Plan denied your request. The Plan says that your benefit is exhausted.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 twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveroutine transportation trips.
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 the medical records, you do not meet the Medicare coverage 
criteria for an IRF admission. You are generally medically stable with Debility with no evidence of medical or 
nursing needs for an IRF. You need physical therapy (PT) and occupational therapy (OT) but not in an IRF. 
There is no evidence of medical issues that require monitoring by an inpatient rehab physician three (3) times a 
week. The documentation does not support that there is a need for an intensive therapy program with 3 hours a 
day and an interdisciplinary approach to rehab care. You need rest breaks and do not have endurance for IRF 
level of therapies. The IRF admission is not medically necessary and also does not meet the Medicare coverage 
criteria due to lack of medical intensity. Your rehab needs can be safely and effectively met in an alternate, less 
intense setting such as in a skilled nursing facility (SNF). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation for the left knee. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried knee surgery and 
steroid injections with suboptimal improvement. The Plan denied your request. The Plan says radiofrequency 
ablation of the genicular nerve is not known to improve health outcomes. 
 
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 requested services. Our physician 
reviewer found that the enrollee has left knee osteoarthritis. She has tried physical therapy, heat and ice, 
massage, and medication trials. This procedure is considered experimental/ investigational. Its role in on-going 
therapy of osteoarthritis is still being defined. There are several on-going clinical trials, however, the enrollee is 
not enrolled in a clinical trial. Therefore, the procedure is deemed 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular radiofrequency ablation for the left knee.
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 the medical records, the enrollee does not meet the Medicare 
coverage criteria for an IRF admission. The enrollee is generally medically stable after a right hip fracture and 
ORIF with no evidence of medical or nursing needs for an IRF. The enrollee needs physical therapy (PT) and 
occupational therapy (OT) but not in an IRF. The enrollee's current functional status does not require IRF level 
of therapies. There is no evidence of medical issues that require monitoring by an inpatient rehab physician 
three (3) times a week. The documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day and an interdisciplinary approach to rehab care. The IRF admission is not 
medically necessary for this enrollee, and also does not meet the Medicare coverage criteria. The enrollee's 
rehab needs can be safely and effectively met in an alternate, less intense setting such as in an skilled nursing 
facility (SNF). 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you are requesting 
the additional routine transportation miles to attend medical appointments. The Plan denied your request. The 
Plan says you have met the Plan limits which have been set in the subscriber agreement. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. You are requesting 
an additional twenty-three (23) miles for a total of seventy-three (73) miles. Your benefit only allows fifty (50) 
miles. You have exceeded your benefit limit. This request is not covered by your health plan. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton treatment delivery; simple, with compensation 
(CPT Code 77522). 
 
You asked the Plan to pre-approve the service. You say that proton therapy is your best treatment option 
because it has less side effects then other treatment options. The Plan denied your request. The Plan says the 
service is not 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the theoretical advantage of proton beam therapy is in its dose distribution. Proton beam 
therapy thus permits the delivery of high doses of RT to the target volume while limiting the "scatter" dose 
received by surrounding tissues.  Use of proton beam RT is expanding as more proton beam treatment centers 
open. However, there are no randomized trials comparing proton beam therapy with photon therapy or 
brachytherapy in men with clinically localized prostate cancer. A systematic review of the available evidence 
from ASTRO on efficacy and toxicity concluded that outcomes were similar with proton beam therapy and 
intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton 
beam approach.  Clinical practice guidelines form the American Urological Association (AUA)/American 
Society for Radiation Oncology (ASTRO)/Society of Urologic Oncology (SUO)/American Society of Clinical 
Oncology (ASCO) conclude that proton beam therapy offers no clinical advantage over other forms of 
definitive treatment. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton treatment delivery; simple, with compensation (CPT Code 77522).
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 there is no documented skilled therapy need which must be at an acute 
inpatient rehab level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plandenied 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 available records, you do not meet Medicare coverage criteria for an IRF admission.You are medically stable after a hip fracture and surgery with no evidence of need for supervision by Physical Medicine and Rehabilitation (PM&R) physician three (3) times a week or needing acute rehab nursing care. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care at the current level of function described above. The IRF admission is not medically necessary. You do not meet the Medicare coverage criteria for an IRF admission due to lack of medical complexity and current level of function. Your rehabneeds can be met in an alternate, less intense setting such as in a skilled nursing facility (SNF).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-approveacute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FASENRA 30mg/ml pen. 
 
You asked the Plan to pre-approve FASENRA. You say that FASENRA is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 FASENRA. Our reviewer says that 
FASENRA is not medically necessary. Our physician reviewer found documentation does not support that the 
enrollee in this case has severe uncontrolled asthma, for which FASENRA (benralizumab) could be considered 
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 FASENRA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve FASENRA 30mg/ml pen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee can safely receive the needed care in another 
setting. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital and when considered medically stable by the 
treating team may be an appropriate candidate for care at a less intense level. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
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 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 for the enrollee.