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 is worried about not making any 
progress at home. You say that the medical records provided support the need for care in an IRF. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says 
that the enrollee's medical care is ongoing and the amount of therapy currently being provided is appropriate to 
meet her needs. 
 
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: 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 you would like the enrollee transferred to an acute 
inpatient rehab. The Plan denied your request. The Plan says Medicare coverage criteria have not been met for 
admission to an acute IRF. 
 
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. Our reviewer 
found that the enrollee's medical status does not currently require intensive physician and nursing oversight 
only in an IRF. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog 100 UNIT/ML Flexpen. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
their Medicare Part B 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 Novolog 100 UNIT/ML 
Flexpen.  
 
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you were using are broke and 
you cannot afford dentures, even with the discount. The Plan denied your request. The Plan says the services 
are not a covered benefit under the plan. 
 
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. The services are not listed in your  dental benefit schedule as a covered 
benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-approve 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOzurdex, dexamethasone, intravitreal implant, 0.1 mg injection (CPT Code J7312).You asked the Plan to pre-approvethe medication. You say that the medication is necessary.The Plan denied your request. The Plan says the member does not have advanced glaucoma with cup to disk ratios greater than 0.8.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs ifthey are medically accepted as safe and effective or appropriate for the particular use. 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 medication. Our physician reviewer found the review has determined that the requested use of Ozurdex is not FDA-approved for the enrollee's diagnosis. It's use in the case in not supported by one of the major drug compendia or by clinical research that appears in aCMS-approved medical journal.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 medication have not been met.Therefore, we decided that the Plan does not have to pre-approveOzurdex, dexamethasone, intravitreal implant, 0.1 mg injection (CPT Code J7312).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
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 a diagnosis of psoriasis 
vulgaris and unspecified arthropathic psoriasis. She has not tried and failed the Plan's required drugs of 
Inflectra or Remicade and Stelara. The records do not support that the required drugs would be contraindicated 
or less effective; therefore, Ilumya 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 Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair and attachments for the enrollee.You asked the Plan to pre-approvea power wheelchair and attachments. You say that the enrollee's current wheelchair needs to be replaced.The Plan denied your request. The Plan says that the enrollee has a wheelchair that is less than five years old.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. The enrollee received a power wheelchair in March of 2017 which is less than five years ago.Therefore, we decided that thePlan does not have to pre-approvea power wheelchair and attachments for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Monovisc. 
 
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 physician reviewer found 
that the enrollee has pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. She 
has failed conservative treatment, and prior trial of Orthovisc. The Plan requires a trial of the drug Monovisc 
before they will approve the requested drug. The documentation does not show that the enrollee has tried and 
failed Monovisc. There is no indication that Monovisc would likely be less effective, or likely have adverse 
effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc One. 
 
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 bilateral primary 
osteoarthritis of the knee. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 
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 Synvisc One.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hereditary kidney cancer genetic testing and Lynch 
Syndrome testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the test is 
not being used to determine chemotherapy treatment decision making. The enrollee does not have a personal 
history of colorectal, breast, or gynecological cancers. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered under certain medical 
indications.  
 
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 requested testing. Our physician 
reviewer found a history of cancer of his right kidney. Lynch syndrome testing is covered only for those with a 
personal history of colon or endometrial cancer. The documentation does not support that there is a familial 
pathogenic variant known or suspected. The testing is not being used to determine a specific diagnosis or 
treatment strategy. The requested testing is not medically reasonable and necessary to treat 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 the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hereditary kidney cancer genetic testing and Lynch Syndrome testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 
(CPT Code 22513). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the records do not show that this injury just happened. The Plan states 
medical studies show that this procedure works best when the enrollee has fractures that happened recently. 
 
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 physician reviewer 
found Medicare coverage criteria have not been met. There is evidence that this fracture is over 12 weeks old, 
with onset of symptoms documented in April 2020. There is no detailed evidence of a recent, reasonable and/or 
comprehensive non-operative treatment protocol trial and failure. The enrollee reported pain control while 
using narcotic medication, and no other conservative treatment is documented, including current pain 
medication. Therefore, the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; thoracic (CPT Code 22513).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Medication Intra-articular Injections of Hyaluronan (Supartz) (J7321 
x5). 
 
You asked the Plan to pay for the injections. You say that the patient has failed conservative care and has 
osteoarthritis. The Plan denied your request. The Plan says that no x-ray report is provided showing that the 
patient does have osteoarthritis. 
 
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 pay for the injections. Our physician reviewer found 
the patient has a preliminary x-ray report of degenerative changes in the knee. The patient has met the other 
criteria of the LCD. The request is medically reasonable and 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 injections have been met. Therefore, we decided that the Plan has to pay for 
Medication Intra-articular Injections of Hyaluronan (Supartz) (J7321 x5).  
 
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: Partially Favorable

 
We decided that the Plan has to pre-approve the CALR testing. We decided that the Plan does not have to pre-
approve the testing.  
 
You asked the Plan to pre-approve the CALR testing. You say that this testing is needed to help with treatment 
planning. The Plan says that these genetic tests are considered experimental. 
 
We decided that the Plan has to pre-approve the CALR testing.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 CALR testing. Our reviewer says 
that only the requested CALR testing is considered reasonable and necessary in this case. Our physician 
reviewer found the NCCN guidelines only support IGH testing for prognosis and therapy-related interventions 
for chronic lymphocytic leukemia (CLL). Since this patient does not have a diagnosis of CCL, this is not 
supported. For CALR testing, this can be supported if there is suspicion for a myeloproliferative neoplasm with 
a JAK2 test being negative. As such, this test is reasonable and 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 CALR testing have been met. Therefore, we decided that the Plan has to 
pre-approve the CALR testing.  
 
We also decided that the Plan does not have to pre-approve the  testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
As noted above, our reviewer finds that there is no support of this testing for the enrollees condition. 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 IGH@ testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the IGH@ testing. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not have complex nursing or medical needs requiring a resource intensive inpatient hospital 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. 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 does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.