Persius/hicric huggingface dataset:
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 enrollee has a wound vac on their hand and is 
unable to do therapy. You say that, due to the enrollee's impaired mobility, lower GI issues, and current 
conditions, they are unable to care for themselves. The Plan denied your request. The Plan says the guidelines 
for coverage have not been met. The Plan says that the enrollee could receive care 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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee'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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneers. 
 
You asked the Plan to pre-approve the labial veneers. The Plan denied your request. The Plan says the 
requested services are outside of your limited dental benefit coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
labial veneers.
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 suffer from Parkinson's Disease and the IRF
offers a more rigorous program that would allow you to achieve faster recovery of mobility and stamina. The
Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does
not require intensive physician and nursing oversight only in an IRF. While you may benefit from additional
therapies such as physical and occupational therapy, the documentation does not support that your functional
status requires an intensive rehabilitation therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve application of Integra bio-engineered soft tissue substitute.
You asked the Plan to pre-approve Integra. You say that to get soft tissue coverage over the enrollee's wound, you will need to do a stage 2 procedure with Integra so that the enrollee's own tissue will start to grow over the Integra and create a wound that will take a skin graft. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this product is considered investigational for this purpose.
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 Integra. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is not sufficient documentation in the medical literature supporting that the use of Integra bio-engineered soft tissue substitute is safe and effective in this 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 Integra have not been met. Therefore, we decided that the Plan does not have to pre-approve application of Integra bio-engineered soft tissue substitute.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the drug does not meet step therapy criteria. 
 
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 Hyalgan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of the right knee. The enrollee has failed 
conservative treatment. The documentation does not support that the enrollee has tried and failed Monovisc and 
Orthovisc. The documentation does not support any indication that Monovisc and Orthovisc would likely be 
less effective and/or likely to 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with accessories. 
 
You asked the Plan to pre-approve the manual wheelchair. You say that you are not able to walk well and feel 
that a wheelchair is necessary. The Plan denied your request. The Plan says the records show that you are able 
to walk household distances with a rolling walker. 
 
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 manual wheelchair. Our reviewer 
says that the documentation does not show that the manual wheelchair is reasonable and necessary. Our 
physician reviewer found the enrollee is an 88-year-old female, with history of atrial fibrillation. She suffered a 
mechanical fall, with resultant pelvic fracture. She was medically stabilized. Now, she is supervised for ADLs 
and is ambulating 200+ feet with a walker, per therapy notes. As the enrollee is ambulatory, it is reasonable to 
anticipate a lesser device, such as a walker, will adequately address mobility and ADL deficits, status post 
fall/fracture.  As such, this request is 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 the manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair with accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT coronary calcium scoring. 
 
You asked the Plan to pre-approve a CT coronary calcium scoring. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT coronary calcium scoring. Our 
reviewer says that the documentation does not support that the requested CT scan is medically reasonable or 
necessary. Our physician reviewer found the enrollee was diagnosed with pure hypercholesterolemia but is 
refusing treatment. The enrollee reports no signs or symptoms of cardiovascular disease. Current treatment 
guidelines recommend considering CT calcium scoring to help decide whether to treat intermediate risk 
enrollees (10-20% Framingham risk of cardiovascular disease related event). Calculating this enrollee's 
Framingham risk score, the enrollee has nearly a 30% risk of cardiovascular risk which is high risk, not 
intermediate risk. Therefore, the enrollee does not meet criteria for the requested 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 a CT coronary calcium scoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT coronary calcium scoring.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization for Euflexxa is correct, because the Plan requires a trial of Orthovisc 
and Monovisc, or contraindication to these drugs, before it will approve Euflexxa. 
 
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. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The 
documentation does not support that Orthovisc or Monovisc would likely be less effective and/or 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided at an out of network
(OON) provider facility.
You asked the Plan to pre-approve office visit. You say that you were approved to see this doctor by the Plan.
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the
requested facility is out-of-network with the Plan and you can be treated by an in-network provider.
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 at an out of network (OON) provider facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care. 
 
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 IRF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that the enrollee has been getting conventional treatment without great success. The Plan denied your request. The Plan says there has been no trial of conservative interventions.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our physician reviewer found that the enrollee complains of acute on chronic lower back pain and left-sided leg pain for several months. She was diagnosed with intervertebral disc degeneration of the lumbar spine in the past, and underwent L5-S1 laminectomy more than 40 years ago. An MRI from 2012 showed spinal stenosis as well as degenerative disc disease and arthritis. In the case of this enrollee, conservative treatments were not exhausted. There was no documentation of the enrollee having tried and failed physical therapy/exercises, appropriate short term medication use, or topical medication options to justify more aggressive interventions. She refused surgery, and her physical findings were not showing evidence of a red flag diagnosis which would require intervention without a trial of conservative treatments. Therefore, this request for MRI 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required contact guard 
assistance with transfers and walking 40 feet with a front wheeled walker. The enrollee required stand-by 
assistance with bed mobility. The documentation does not support that the enrollee requires the specialized 
skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing 
or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be safely met at a lower level of 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was medically stable, with no evidence of a need for supervision by a 
PMR physician. There is no need for acute rehab nursing care. Functionally, given the enrollee's current 
functional level, he does not require the IRF level of therapy. He may benefit from further PT and OT and 
speech but does not require an intensive 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is feasible to meet the enrollee's needs at a lower level of care, such as home with 
supervision and home health services, assisted living facility with home health services, or long term care with 
intermittent services if the services are approved by the plan. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex 
wound care or other ongoing SN need. Your functional level does not require skilled therapy services with the 
specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment in a SNF and appears to be a new baseline. You do not require skilled 
nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, 
you do not require the necessary services on 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray and extraction provided on March 2, 
2020. 
 
You asked the Plan to pay for the panoramic x-ray and extraction. You say that you paid your bill in good faith, 
planning that the Plan would cover it. You also say that you are on a limited income. The Plan denied your 
request. The Plan says the treating provider has opted out of the Medicare program from May 18, 2016 to May 
18, 2022. The Plan also says there were no contacts to the Plan in regard to your cost share or provider 
information prior to receiving the services. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the panoramic x-ray and extraction provided on March 2, 2020.