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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health services. 
 
You asked the Plan to pre-approve the inpatient mental health services. You say that you would like 
reconsideration because these services are medically necessary. The Plan denied your request. The Plan says 
there is no evidence that the member's treatment needs could not be met at a less restrictive, outpatient level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient mental health services. 
Our reviewer says that it was not expected this enrollee would improve in a reasonable period of time as she 
did not have dangerousness to self or others, auditory or visual hallucinations or behaviors including any threat 
to acute safety. She was cooperative and compliant with treatment. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. 
Our physician reviewer found it did not appear that active treatment was taking place. It did not appear that the 
services were reasonably expected to improve the member's condition or for the purpose of diagnosis. 
 
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 inpatient mental health services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stravix skin graft material to be used, for the enrollee. 
 
You asked the Plan to pre-approve Stravix skin graft material. You say that the services are necessary. The 
Plan denied your request. The Plan says Stravix (a type of skin graft material) is not a standard treatment for 
skin repair after jaw surgery and there is not enough medical proof that shows the safety and/or success of 
Stravix when used for this reason. 
 
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 Stravix skin graft material. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it has not been demonstrated that Grafix Stravix Prime skin graft material 
is medically reasonable and necessary for the proposed procedure 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 Stravix skin graft material have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Stravix skin graft material to be used, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Artiss fibrin sealant. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were 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 these services. Our reviewer says that 
the services were not medically necessary. Our physician reviewer found the enrollee has osteomyelitis of the 
left knee and underwent debridement of the soft tissue on December 2, 2019. Artiss is a fibrin sealant indicated 
to adhere autologous skin grafts to surgically prepared wound beds resulting from burns, and to adhere tissue 
flaps during facial rhytidectomy surgery (face-lift). The documentation does not support the use of Artiss fibrin 
sealant in the setting of split-thickness skin grafts following debridement of soft tissue on the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Artiss fibrin sealant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea (J0178). You say that you want the enrollee to be treated with this 
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to bevacizumab (Avastin). 
 
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 (J0178). Our reviewer says that 
the drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not tried and 
failed the required drug and the medical records provided there is no indication that the plan's required drug 
would likely be less effective and/or likely have adverse effects 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 Eylea (J0178) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient 
rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that you are medically stable with no evidence of a need for supervision by a physical 
medicine and rehabilitation physician or a need for acute rehabilitation nursing care. You may benefit from 
further physical and occupational therapy but do not require an intensive therapy program. An IRF admission is 
not medically necessary based on the lack of medical complexity. Additionally, your rehabilitation needs can 
be provided in a lower intensity alternate setting such as in a skilled nursing facility. 
 
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 an 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 you would like reconsideration because you are 
unable to stand without support. The Plan denied your request. The Plan says you can safely receive necessary 
services in another setting. 
 
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 your nursing. medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. At the current level of 
function, you do not require IRF level therapies. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthesis (L5671, L5650, L5925, L5651, L5950, 
L5590, L5624, L5649, L5673, L5695, L5920, L5974, L5812, L5850, L8460, L8480, L8430, L5845). 
 
You asked the Plan to pre-approve a new prosthesis. You say that the items 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 a new prosthesis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a lack of medical data to support the items. 
 
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 new prosthesis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a new prosthesis (L5671, L5650, L5925, L5651, L5950, L5590, L5624, L5649, L5673, 
L5695, L5920, L5974, L5812, L5850, L8460, L8480, L8430, L5845).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc Hyaluronic acid knee injections.
You asked the Plan to pre-approve Monovisc Hyaluronic acid knee injections. You say that the results of this drug have been outstanding. The Plan denied your request. The Plan says that the injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There are no medical records in the case file. Therefore, we decided that the Plan has to pre-approve Monovisc Hyaluronic acid knee injections.
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because 
the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member can 
safely receive 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. Our 
physician reviewer found the member does not require any services at the LTACH that are not already 
available at the current facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 provided shows that this patient requires additional acute care 
services. Current pulmonary status suggests he is not yet stable to transfer at this time. Also, the clinical status 
does not suggest a likely need for acute care services for at least 25 days. The patient does not require any 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility.  Therefore, this request 
for LTACH services will be considered not medically necessary at this time. Transfer may be considered at a 
later date when pulmonary status is more stable. 
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic kidney disease 
and anemia. The records do not show that he has tried and failed the Plan's required drug, Retacrit. The records 
do not support that the required drug would be contraindicated or less effective; therefore, Aranesp 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa (J7323). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to Synvisc/Synvisc One or Durolane/Gelsyn-3. 
 
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 Euflexxa (J7323). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical 
records provided the enrollee has not tried and failed the required drugs and there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects 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 Euflexxa (J7323) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aloxi. 
 
You asked the Plan to pre-approve Aloxi. You say that the medication is 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 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 Aloxi. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Aloxi is indicated for the prevention of 
nausea and vomiting associated with moderately and highly emetogenic cancer chemotherapy. NCCN 
Guidelines Version 2.2020 Antiemesis lists the emetogenic potential of Pembrolizumab as minimal (less than 
10% frequency of emesis). 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VertiFlex Superion Interspinous Spacer. 
 
You asked the Plan to pre-approve the VertiFlex Superion Interspinous Spacer. You say that you would like 
reconsideration because this device is medically necessary. The Plan denied your request. The Plan says the 
requested device is contraindicated per FDA guidelines. 
 
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 VertiFlex Superion Interspinous 
Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for this enrollee's medical condition as discussed above. There is no discussion relative to 
why this enrollee would not be indicated for standard decompression surgery. 
 
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 VertiFlex Superion Interspinous Spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a VertiFlex Superion Interspinous Spacer.