Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee prosthetics evaluation and fitting (97763) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a knee prosthetics evaluation and fitting (97763) to be provided by an OON) 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide this service. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a knee prosthetics evaluation and fitting (97763) 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 a genicular nerve block. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered for a diagnosis of osteoarthritis. 
 
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 block. Our reviewer says that the 
requested block is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental/investigational procedure for patients following TKR. It is the subject of on-going 
clinical trials. The enrollee is not enrolled in a clinical trial. 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an 
inpatient rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that you are medically unstable to transfer to an acute inpatient rehabilitation facility 
and need care at the current acute care facility. You may benefit from continuing physical and occupational 
therapy when stable but you cannot tolerate and benefit from 3 hours of intensive therapy 5 days a week due to 
continued need for treatment of acute hypoxic respiratory failure. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been 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 Aranesp. Our reviewer says that the 
criteria for coverage of Aranesp have not been met. Our physician reviewer found the plan requires an 
inadequate response to Retacrit therapy for at least two consecutive months with appropriate dose adjustment 
before they will approve Aranesp.  The enrollee does not satisfy the plan's step therapy criteria, and there is 
insufficient documentation that the drug required by the plan's step therapy criteria is not medically appropriate 
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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dexamethasone/methylprednisolone provided in an 
intramuscular injection on March 11, 2020. 
 
You asked the Plan to pay for the dexamethasone/methylprednisolone. You say that this should be covered as a 
treatment for the enrollee's condition. The Plan denied your request. The Plan says there is no support for this 
treatment for uncomplicated rhinitis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the dexamethasone/methylprednisolone. Our 
reviewer says that the drugs provided in this case are not considered reasonable and necessary. Our physician 
reviewer found Submitted documentation, Medicare guidelines, and Medicare approved compendia were 
considered. The enrollee has a diagnosis of acute allergic rhinitis.  The enrollee was evaluated by a primary 
care provider and diagnosis with sinusitis.  Treatment plan included the intramuscular injection and oral 
antibiotics for the diagnosis of sinusitis.  Review of the compendia do not support the use of intramuscular 
glucocorticosteroids for the treatment of uncomplicated sinusitis.  
 
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 dexamethasone/methylprednisolone have not been met. Therefore, we 
decided that the Plan does not have to pay for the dexamethasone/methylprednisolone provided in an 
intramuscular injection on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance spectroscopy testing. 
 
You asked the Plan to pay for magnetic resonance spectroscopy. You say that this test can help further 
determine the etiology of the enrollee's condition. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that magnetic resonance spectroscopy is not covered 
by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of magnetic resonance spectroscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for magnetic resonance spectroscopy testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult sized disposable protective underwear/pull-on 
(T4526). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have an overactive bladder and is 
disabled and cannot walk fast enough to make it to the bathroom in time. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve adult sized disposable protective 
underwear/pull-on (T4526).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs incontinence 
supplies. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder 
(73221) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary and you are in North 
Carolina. The Plan denied your request. The Plan says non-emergent out-of-network services are not covered. 
 
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 Magnetic 
Resonance Imaging (MRI) of the shoulder (73221) 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 Gabapentin 100mg capsule for the enrollee. 
 
You asked the Plan to pre-approve the drug. 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 Gabapentin 100mg capsule 
for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Xofigo radiopharmaceutical therapy (79101, A9606). 
 
You asked the Plan to pre-approve Xofigo radiopharmaceutical therapy. You say that this is the best treatment 
option. The Plan denied your request. The Plan says that the records do not show that this is medically 
necessary. 
 
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 Xofigo radiopharmaceutical therapy. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found enrollee's condition supports coverage of Xofigo radiopharmaceutical therapy. 
This is further supported by Medicare approved compendia (Micromedex). The enrollee meets criteria in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xofigo radiopharmaceutical therapy have been met. Therefore, we decided that 
the Plan has to pre-approve Xofigo radiopharmaceutical therapy (79101, A9606).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has had a complicated course, and the documentation supports that the complexity of her 
nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee has a reasonable expectation to be able to fully participate in and 
benefit from intensive rehabilitation therapy programs. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a history 
of diabetes, chronic kidney disease, sleep apnea, and morbid obesity, who underwent a right hip replacement 
on 8/18/20. An occupational therapy frequency of 3 - 5 times per week was recommended.  
 
The documentation does not demonstrate that the complexity of the enrollee's nursing, medical and 
rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee is generally medically stable and the documentation does not support that she has complex 
medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab 
physician three times per week. While the enrollee is reasonably expected to benefit from continuing physical 
therapy and occupational therapy, the documentation does not support that there is need for an intensive 
therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary 
approach to rehabilitation 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atorvastatin 20mg tablets. 
 
You asked the Plan to pre-approve Atorvastatin. You say that Atorvastatin is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Atorvastatin 20mg tablets.  
 
Benefits for Atorvastatin 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: Partially Favorable

 
We decided that the Plan has to pre-approve one ESI. We decided that the Plan does not have to pre-approve 
two further ESIs.  
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that 
the services are not medically necessary. 
 
We decided that the Plan has to pre-approve one ESI.  
 
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 
one ESI is reasonable and medically necessary. Our physician reviewer found the enrollee has lumbosacral 
spondylosis without myelopathy or radiculopathy and spinal stenosis with neurogenic claudication. She 
presents with chronic low back pain rated at 10 out of 10 radiating to the right leg. There is no role for a series 
of three ESIs. Each injection must be evaluated for degree of effectiveness and duration of pain relief. 
Additional injections should be considered only if the first produces sustained pain relief. A single ESI 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 one ESI have been met. Therefore, we decided that the Plan has to pre-approve 
one ESI.  
 
We also decided that the Plan does not have to pre-approve two further ESIs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of two further ESIs are not met. Therefore, we decided that the Plan does not have 
to pre-approve two further ESIs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like to see this doctor. You say 
that you used this doctor 25 years ago. The Plan denied your request. The Plan says there are in-network 
providers available for these services. 
 
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 
physician services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve functional electrical stimulator (E1399 NU) to be 
provided by an out of network provider. 
 
You asked the Plan to pre-approve functional electrical stimulator. You say that based on the medical necessity 
guidelines it is clear that the intended application of the RT300 FES therapy system is medically appropriate 
and necessary to meet your basic health care needs. The Plan denied your request. The Plan says electric nerve 
stimulation to treat motor function disorders is not reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of functional electrical stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve functional electrical stimulator (E1399 NU) to be provided by an out of network provider.