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

We decided that the Plan does not have to pre-approve arthrodesis, lumbar.
You asked the Plan to pre-approve arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558), arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) (22585). You say that the enrollee needs lumbar arthrodesis because of severe back pain. The Plan denied your request. The Plan says the enrollee has not tried and failed 3 consecutive months of conservative treatment.
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 arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (22558), arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) (22585). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal surgery is not met. There has not been an adequate trial and failure of physical therapy for at least 3 months. More physical therapy is needed for back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar arthrodesis (22558, 22585) have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, lumbar.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. You say that the in-network provider is 45 minutes away. The 
Plan denied your request. The Plan says the services are available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home PT/INR monitoring system to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the home PT/INR monitoring system. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 home PT/INR monitoring system 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 Praluent. 
 
You asked the Plan to pre-approve Praluent. You say that you would like reconsideration because this 
medication is medically necessary. The Plan denied your request. The Plan says this medication falls under 
Medicare Part D and the member does not have a pharmacy benefit with the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent.  
 
Benefits for Praluent 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee continues to need skilled 
rehabilitation. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Although you have skilled therapy 
needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve 
the SNF admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 125mg/ml Orencia injection. 
 
You asked the Plan to pre-approve Orencia. You say that you would like reconsideration because the member 
has been on this medication since 2019 and is doing extremely well on it. The Plan denied your request. The 
Plan says this medication is a Part D drug and the member does not have a pharmacy benefit with the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the 125mg/ml Orencia 
injection.  
 
Benefits for Orencia 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that the enrollee is on a home blood glucose monitor 
and tests three times per day. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The records show that the enrollee is not insulin treated. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation 
benefit. 
 
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 Plan's rules. Based on this information, we 
decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the Plan 
contract allows for 24 one-way trips every year to Plan approved locations. You have utilized 21 of the 
allowable 24 one-way trips thus far. Your request to the Plan for additional trips exceeds the allowable 
transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional trips for 
routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Implantation or replacement of carotid sinus baroreflex 
activation device (0266T). 
 
You asked the Plan to pre-approve carotid sinus baroreflex activation device. You say that both the provider 
and the enrollee believe this denial to be made in error and wish for a complete review of all provided material. 
The Plan denied your request. The Plan says this service is considered experimental and investigational as this 
device is not the standard of medical practice for the treatment of heart failure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of carotid sinus baroreflex activation device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Implantation or replacement of carotid sinus baroreflex activation device 
(0266T).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
enrollee does not meet criteria for IRF admission. 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 was admitted for weakness and a urinary tract 
infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve this service. You say that continued inpatient psychiatric hospital care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of continued inpatient psychiatric hospital 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 this service. Our reviewer says that 
continued inpatient psychiatric care is not medically necessary. Our physician reviewer found that the enrollee 
was admitted to the acute inpatient psychiatric hospital on April 3, 2021 with Vascular Dementia with 
Behavioral Disturbance. Based upon the review of the records provided, it was not expected that this enrollee 
would improve in a reasonable period of time beyond the date in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations, and was without aggressive behaviors while 
not showing any acute threats of safety. 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 beyond the date in 
question. It did not appear that active treatment was taking place beyond the date in question. It did not appear 
that the services for the date in question were reasonably expected or medically necessary to improve the 
patient?s condition or were for the purpose of diagnosis. This enrollee did not require inpatient mental health 
treatment beyond the date in question of April 8, 2021, as he was not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions, and was not showing any behaviors or aggression. He was 
being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric hospital care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injection, 300mg/2ml. 
 
You asked the Plan to pre-approve Dupixent injection. You say that the enrollee suffers from dermatitis and 
pruritis. You also say that the enrollee has tried and failed numerous topical steroids. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under 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 Dupixent injection, 
300mg/2ml.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio (Q5101). 
 
You asked the Plan to pre-approve Zarxio. You say that this request is medically necessary. The Plan denied 
your request. The Plan says the claims for this clinical trial are not covered by your Medicare Advantage plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Zarxio as part of a clinical trial. The Plan does not cover routine 
costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Zarxio (Q5101).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Finasteride. 
 
You asked the Plan to pre-approve Finasteride. The Plan denied your request. The Plan says this 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 Finasteride.  
 
Benefits for Finasteride 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 request for LTACH care is medically 
necessary. The Plan denied your request. The Plan says LTACH care is not medically necessary as the enrollee 
is stable and does not have a complex enough condition to warrant a 25-day LTACH admission. 
 
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 enrollee is a 72-year-old female with a history of hypertension, hyperlipidemia 
and gastroesophageal reflux disease who was admitted into the hospital after gall bladder surgery on March 15, 
2021. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for Supartz FX is correct, because the plan 
requires a trial of Orthovisc and Monovisc before it will approve Supartz FX. 
 
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 
enrollee does not meet the criteria for a step therapy exception for Supartz FX. Our physician reviewer found 
the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. There is no 
documentation as to why these preferred drugs would not be expected to be safe and effective for the enrollee, 
or that the enrollee is allergic or intolerant to the Plan's preferred drugs. 
 
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 use of Supartz FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).

You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the documentation does not reveal that the patient requires other types of input devices or accessories that would require the use of the expandable controller.

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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).