Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power adjustable seat and power adjustable leg rests. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says durable medical equipment is an item that is medical in nature, can be used repeatedly, 
and is used in the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power adjustable seat and power adjustable leg rests.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON laboratory services. You say that the enrollee's peripheral blood 
specimen was submitted to an out of network laboratory. You say that, in order to maintain specimen integrity, 
CAP recommends all peripheral blood specimens be fixed for no more than 48 hours. You say that you want to 
ensure that there are no delays in testing a specimen of this nature. The Plan denied your request. The Plan says 
the enrollee's needs can be met 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 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 
laboratory services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been previous back surgery. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the NCD 
specifically excludes pain that is related to past surgery as is the case here. Therefore, the request is considered 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sodium hyaluronate. 
 
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 pain related to left knee 
osteoarthritis confirmed on imaging studies. She has not tried and failed the Plan's required drugs of Orthovisc 
and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; 
therefore, the sodium hyaluronate 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 sodium hyaluronate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections of levels L3-L4 and L4-L5. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee's pain is radiating from the 
hip rather than from the lower back. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the enrollee's pain is not limited to the back. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint injections are covered under the 
indications 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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found the presence of radicular pain in the setting or prior spine surgery is an exclusion for facet 
diagnostic blocks. Therefore, this procedure is 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections of levels L3-L4 and L4-L5.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve timolol maleate eye drops. 
 
You asked the Plan to pre-approve the eye drops. You say that this medication is necessary. The Plan denied 
your request. The Plan says this is a self-administered drug which cannot be covered 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 timolol maleate eye drops.  
 
Benefits for the eye drops 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device 
(Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this would provide significant clinical and quality of 
life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this 
procedure is correct, because Vertiflex is not medically necessary and the enrollee is not enrolled in an 
approved study for it. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous stabilization device (Vertiflex).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Zoledronic acid, or have a history of osteoporotic fracture. 
 
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 Prolia. Our physician reviewer found 
that the enrollee has been diagnosed osteoporosis and gastric/stress ulcers. The enrollee had not reported any 
prior or current fracture, nor was there any noted contraindication to Zoledronic acid, which is an IV 
bisphosphonate which would not aggravate gastritis symptoms. There appears to be no clear advantage to using 
Prolia over Zoledronic acid in this clinical case. Therefore, Prolia will be considered 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% eye drops. 
 
You asked the Plan to pre-approve the eye drops. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 
drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% eye drops.
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 aggressive therapy and close 
physician monitoring. The Plan denied your request. The Plan says the enrollee does not need to see a rehab 
doctor 3 times a week, or need a team for a complex rehab design. 
 
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 has oxygen dependent chronic lung disease and has had increased falling at home. She is 
living in the home, and her medical problems are stable. 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 medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dermatology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON dermatology services. You say that the enrollee needs this surgery 
and it is felt that the delay to see a network provider is too long. You feel this should be covered as in-network. 
The Plan denied your request. The Plan says there were network dermatologist available who could be seen 
within a reasonable time frame. 
 
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 dermatology services to be provided by an out of network (OON) provider.
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 enrollee requires ongoing aggressive 
medical intervention. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care, and does not require transfer. 
 
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 the enrollee was admitted to the current acute care hospital for evaluation and removal of 
infected left knee hardware, bilateral foot ulcerations, and MSSA bacteremia. The hospital course was 
complicated by acute kidney injury requiring hemodialysis, and acute on chronic congestive heart failure. He 
requires ongoing wound care and hemodialysis, although the infection has been managed well. The enrollee 
appears to be improving, but still requires additional short term (less than 25 days) of additional acute care 
services. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current hospital. Therefore, this request for LTACH services will be considered not medically 
necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute physical therapy will give you more time than 
in a skilled nursing facility. The Plan denied your request. The Plan says you do not have a complex unstable 
medical problem that requires the services of a physician. 
 
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 you are at an independent level for eating and seated grooming, moderate assist for lower body bathing and 
dressing, and minimal assist for toilet transfers. You do not require the intensity of services provided at an IRF. 
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says the facility chosen is not in-network with the Plan. 
 
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 medical services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FluidFlow amniotic membrane allograft for knee 
arthritis. 
 
You asked the Plan to pre-approve the amniotic membrane allograft. You say that this is necessary as other 
treatments have failed. The Plan denied your request. The Plan says this treatment is currently experimental 
and not proven safe/effective. 
 
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 amniotic membrane allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a male with pain related to osteoarthritis of both knees (left 
worse than right), diagnosis confirmed with imaging studies. He has failed conservative treatment. Fluid Flow 
amniotic membrane allograft treatment has been requested. Based on the medical records provided and the 
current Medicare guidelines, there is no documentation that the Fluid Flow amniotic membrane allograft at 
issue in this case medically reasonable and necessary. There is no indication in the current medical literature or 
Medicare guidelines that the Fluid Flow amniotic membrane allograft is safe and effective for knee arthritis. 
 
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 amniotic membrane allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FluidFlow amniotic membrane allograft for knee arthritis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexlizet. 
 
You asked the Plan to pre-approve Nexlizet. You say that the enrollee was unable to tolerate other drugs. The 
Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexlizet.  
 
Benefits for Nexlizet 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 two lite speed plastic wheels and a push rim activated 
power system. 
 
You asked the Plan to pre-approve the wheels and power system. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the clinical information we 
received does not meet the guidelines for two lite speed plastic wheels and a push-rim activated power assist 
system. 
 
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 wheels and power system. Our 
reviewer says that the requested wheels are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not meet criteria for the push-rim activated power assist system as you have 
not been self propelling in a manual wheelchair for at least one year. 
 
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 wheels and power system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve two lite speed plastic wheels and a push rim activated power system.