Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric days from September 
25, 2020 and forward. 
 
You asked the Plan to pre-approve additional inpatient psychiatric days. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says the enrollee has exhausted the lifetime 
inpatient psychiatric benefit and no further care can be provided. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for inpatient psychiatric care is limited 
to 190-days in a patient's lifetime. The contract with the Plan also states this.  
 
Based on the Medicare database, the enrollee has received 190 days of inpatient psychiatric care. As such, no 
further inpatient psychiatric coverage is available. Therefore, we decided that the Plan does not have to pre-
approve additional inpatient psychiatric days from September 25, 2020 and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve office services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-
network with the Plan and you can be treated by an in-network pain management specialist. 
 
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 out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional ten (10) PT visits provided from June 3, 
2020, through December 31, 2020. 
 
You asked the Plan to pre-approve the additional ten (10) PT visits provided from June 3, 2020, through 
December 31, 2020. The Plan denied your request. The Plan says the additional PT visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional ten (10) PT visits 
provided from June 3, 2020, through December 31, 2020. Our reviewer says that skilled services are not 
necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician 
reviewer found there is only one PT note dated July 15, 2020 that has goals to achieve in 6 weeks for short term 
and 12 weeks for long term goals. The plan is to progress to next visit. No further documentation is provided to 
assess the effect of therapy or achievement of goals and need for additional therapy visits. The documentation 
provided does not meet the Medicare coverage criteria for the requested PT visits.  
 
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 additional ten (10) PT visits provided from June 3, 2020, through December 
31, 2020. have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 
ten (10) PT visits provided from June 3, 2020, through December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that you are appealing with records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
procedure is experimental/investigational. 
 
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 radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational therapy because of the wide 
variation of efficacy reported in literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the lateral sacral branches.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress transthoracic echocardiogram (TTE) (93351). 
 
You asked the Plan to pre-approve a stress TTE. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 
met. 
 
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 a stress TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance of a clinically stable enrollee with no symptoms or findings concerning for 
ischemia the records do not support the medical necessity for a repeat stress echocardiogram at this time. 
Coverage criteria are not met since the test exceeds the enrollee's medical needs at this time based on the 
records provided. 
 
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 stress TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stress transthoracic echocardiogram (TTE) (93351).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that you have an abscess and your face is swollen. 
You say that you need to see an oral surgeon. The Plan denied your request. The Plan says the Plan only covers 
dental services provided by a participating general dentist. 
 
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 service is not among 
those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does 
not have to pre-approve the extraction to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you have weak legs and have fallen 
between the toilet and wall. 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 raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for A. Wolf, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2361, 
E1028, E2377, E2313, E1007, E2620, E2311, E1028, K0108, E1012, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the patient is unable to 
ambulate community distances. The Plan denied your request. The Plan says this is not covered for use outside 
the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair (K0861) and accessories (E2361, E1028, E2377, E2313, E1007, 
E2620, E2311, E1028, K0108, E1012, E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty scooter (power operated vehicle). 
 
You asked the Plan to pre-approve scooter. You say that the scooter you previously received is not 
comfortable. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because you should potentially use a power wheelchair instead of a scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
 
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 scooter. Our reviewer says that you do 
not meet the Medicare criteria for the requested heavy-duty scooter. Our physician reviewer found you are 
unable to propel a manual wheelchair and need a power mobility device. However, given your condition, you 
would potentially benefit from using a power wheelchair instead of the requested scooter. You obtained your 
current scooter less than 5 years ago and therefore do not require another. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of scooter have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a heavy-duty scooter (power operated vehicle).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to zoledronic acid 
 
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 (J0897). Our reviewer says that 
the drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of 
Zoledronic acid (generic Reclast) before they will approve the requested drug. In this case, that enrollee has not 
tried and failed the required drug. There is no documentation provided indicating that the Plan?s required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. The enrollee does not have a 
history of osteoporosis related fracture. 
 
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 (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab 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 NCCN recommends this treatment only for cancers that are stage 3. 
 
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 pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the use of Durvalumab 
after chemo-radiation is indicated and supported for use in stage III NSCLC. Per the NCCN Guidelines Version 
8.2020 page NSCL-3 the requested use does not meet NCCN recommendations. Therefore, the documentation 
does not support that Durvalumab is medically reasonable and necessary for the enrollee. The documentation 
does not support that the drug is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durvalumab for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to provide Ruxience. 
 
You asked the Plan to provide Ruxience (Rituximab) Q5119. You say that you want the enrollee treated with 
this drug. The Plan denied your request. The Plan says that there is no evidence this drug would show better 
long-term health outcomes for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they 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 provide Ruxience (Rituximab) Q5119. Our reviewer 
says that the use of this drug is supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Our physician reviewer found the documentation supports that the 
requested drug is safe and effective and otherwise reasonable and necessary for this 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 Ruxience (Rituximab) Q5119 have been met. Therefore, we decided that the 
Plan has to provide Ruxience.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz FX. 
 
You asked the Plan to pre-approve Supartz FX. The Plan denied your request. The Plan says the enrollee has 
not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Supartz FX. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician reviewer 
found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step 
therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
Supartz FX is not approved, as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz FX.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from 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 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 the 
requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show no measurements for the first month. 
 
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 therapy. Our reviewer says that the 
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no objective evidence of a measurable improvement from prior wound VAC use to determine 
if additional use of this device would be helpful. The wound was not documented as having been measured. 
Therefore, this request for continued use of the negative pressure wound device will be considered not 
medically necessary based on the documentation provided. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve negative pressure wound therapy (NPWT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is needed to complete activities of daily living. 
The Plan denied your request. The Plan says this does not serve a primarily medical purpose. 
 
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 seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the incisional biopsy. You say that you need this surgery in order to have 
teeth. The Plan denied your request. The Plan says this service is not a covered benefit under your benefit 
package. 
 
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 an 
incisional biopsy of oral tissue (D7286).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that you need shots of Euflexxa every six months. The 
Plan denied your request. The Plan says you last received a Euflexxa injection on May 5, 2020. The Plan also 
says that you are not covered for another knee injection until six (6) months have passed after your last 
injection. 
 
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 pre-approve Euflexxa. Our reviewer says that the 
administration of Euflexxa in less than 6 months of the last injection does not meet coverage criteria. Our 
physician reviewer found the documentation does not support that the administration of Euflexxa in less than 6 
months of the last injection, is medically reasonable and necessary for you. The documentation does not 
support that the administration of Euflexxa (J7323) in under less than 6 months of the last injection is safe or 
effective for you. 
 
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 (J7323).