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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require are called custodial care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device to decrease pain and swelling in their neck. The Plan denied your request. The Plan says devices used to 
treat swelling in the head or neck are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
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 enrollee requires daily physician visits, and 
aggressive therapy to ensure a safe transition back home. The Plan denied your request. The Plan says the 
enrollee's needs are not complex, and she doesn't need an intensive team for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee is at contact guard assist for bed mobility, transfers, and walking. She is generally medically 
stable with dementia and debility, with no recent neurological or orthopedic events. There is no evidence of 
complex medical issues that require monitoring by an inpatient rehab physician three times per week, or a need 
for acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is 
no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician 
oversight and an interdisciplinary approach to rehabilitation care. The documentation does not support the need 
for IRF admission medically or functionally. 
 
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: Favorable

 
We decided that the Plan has 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 that 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is currently undergoing treatment at a LTACH, where they are receiving 
intravenous (IV) antibiotics four times a day. Therefore, the enrollee does have acute care needs. As a practical 
matter, providing such services at a lower level of care is not reasonable. There is no evidence that the enrollee 
requires services that are not currently available. Therefore, transfer to another LTACH or acute care hospital 
(ACH) is not medically necessary. The enrollee can remain at the current LTACH until such time no acute 
services are required (i.e. the IV antibiotics are completed). 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) 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: 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 the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says SNF services are not medically necessary. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs. The enrollee was treated for a UTI and had routine 
Foley catheter care. The enrollee had uncomplicated wound care to his lower extremities and left buttocks. The 
enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a 
moderate to maximal assist level for bed mobility. The enrollee required varying assist with activities of daily 
living. There are no further identifiable skilled therapy service needs. There are no further identifiable skilled 
nursing service needs. 
 
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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not 
had an inadequate response to Retacrit for at least two consecutive months, with appropriate dose adjustment. 
 
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 Aranesp. Our physician reviewer found 
that the enrollee is noted to have anemia in the setting of chronic kidney disease. The Plan requires a trial of 
Retacrit before they will approve the requested drug. There is no evidence that the enrollee is allergic to or 
intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no 
documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Therefore, 
the requested Aranesp is not shown to be currently medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of a skilled nursing facility admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that an 
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the 
enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Rituximab injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the Medicare-approved resources do not support this drug for the enrollee's use. 
 
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 injection. Our reviewer says that the 
requested injection is medically reasonable and necessary. Our physician reviewer found stiff person syndrome 
is a rare disease. Treatments often come under orphan status. There are case reports indicating a response to 
some patients to rituximab. This enrollee is documented as having a prior response. The service is reasonable 
and 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve a Rituximab injection for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits 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 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 
office visits 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 Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. 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 Udenyca. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Udenyca is indicated for the prophylaxis 
of febrile neutropenia in enrollees with non-myeloid malignancies receiving myelosuppressive anti-cancer 
drugs. At this time, the documentation does not support that the enrollee is on a myelosuppressive 
chemotherapeutic regimen, or that the enrollee has agranulocytosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is now mostly maximum assist for 
care. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level 
of care (including custodial center placement). The enrollee's vital signs are stable, and ongoing SNF is deemed 
not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device (22869). 
 
You asked the Plan to pre-approve a interspinous and/or interlaminar device. 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 a 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 device is experimental. More research is needed to 
show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a interspinous and/or interlaminar device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a interspinous and/or interlaminar device (22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve Avastin. You say that Avastin is medically necessary. The Plan denied your 
request. The Plan says a trial of Mvasi and Zirabev is required before Avastin can be approved. 
 
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 Avastin. Our reviewer says that Avastin 
is not medically necessary at this time. Our physician reviewer found there was no trial of the plan preferred 
drugs. There is no reason Mvasi and Zirabev would be unsafe or ineffective 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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
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. The Plan denied your request. The Plan says you do 
not require services in the LTACH that are not available where he is currently being cared for. 
 
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 physician 
reviewer found that you are currently undergoing treatment at an acute care hospital (ACH), having been 
admitted with perforated ulcers, which were subsequently complicated by sepsis and fungemia. You are not 
intubated/ventilated.  There is no evidence that you require services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VQ scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an approval code for the same or similar study on file, and the guidelines do not 
support additional imaging without knowing the outcome of the prior approval. 
 
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 scan. Our reviewer says that the 
requested scan is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the review of the reports of the prior CTAs dated 3/15/19 and 2/11/20 show no documentation of urticarial 
reaction or for that matter any allergic reaction to contrast. The order for the 6 month CTA follow-up is still 
valid. The necessity of the VQ scan in lieu of the approved CTA has not been established in the records 
provided. If the enrollee indeed has had an allergic reaction to contrast, one would expect such a reaction to be 
documented in the written reports of the CTA studies. If for some reason an allergic reaction occurred with 
contrast injection, such a complication should have been mentioned in the reports. Of note is the marked 
superiority of CTA over VQ scan in the documentation of pulmonary emboli. 
 
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 a VQ scan for the enrollee.