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

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning 
August 7, 2020. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 was admitted to the 
hospital on August 5, 2020 with acute psychotic disorder. Based on the submitted records, it is not expected 
that she will improve in a reasonable period of time beyond the date in question, as she is not showing suicidal 
or homicidal ideation and has no auditory or visual hallucinations. She is not showing dangerousness to self or 
others and is compliant with treatment. It does not appear that active treatment is taking place beyond the date 
in question. Continued inpatient services are 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 continued inpatient psychiatric services beginning August 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 determineif the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does 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. The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's 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. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve complete replacement of shoulder joint surgery. 
 
You asked the Plan to pre-approve complete replacement of shoulder joint surgery. You say that the requested 
complete replacement of shoulder joint surgery is medically necessary. The Plan denied your request. The Plan 
says that the requested complete replacement of shoulder joint surgery is not medically necessary. 
 
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 complete replacement of shoulder joint 
surgery. Our reviewer says that the requested complete replacement of shoulder joint surgery is medically 
necessary. Our physician reviewer found the enrollee presents status post right shoulder rotator cuff repair on 
10/17/18 and right shoulder superior capsule reconstruction on 1/9/19. It is noted that his superior 
reconstruction has failed. He presents with progressively worsening right shoulder pain with associated 
weakness, decreased range of motion, pain at rest, and crepitance of the shoulder. Functional limitations are 
noted in activities of daily living and pain affects his quality of life. Clinical exam findings are documented 
consistent with right shoulder rotator cuff arthropathy and glenohumeral arthritis. He has reportedly failed 
extensive physical therapy, subacromial corticosteroid injections, home exercise, and activity modification. 
Under consideration is a request for right reverse total shoulder arthroplasty. Current evidence based medical 
literature supports reverse total shoulder arthroplasty in this enrollee's clinical setting. Therefore, this request 
for right reverse total shoulder arthroplasty would be considered medically reasonable and necessary for 
treatment of this enrollee's medical 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 complete replacement of shoulder joint surgery have been met. Therefore, we 
decided that the Plan has to pre-approve complete replacement of shoulder joint surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Prednisone is not covered under the enrollee's Medicare Part B 
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 Prednisone.  
 
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor for a Freestyle Libre continuous glucose 
monitor (CGM). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM and related supplies are 
covered when specific criteria are met. 
 
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 enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a diagnosis 
of Type II diabetes treated with one daily insulin injection. She does not meet the criteria for coverage for a 
therapeutic CGM and sensor. The services are therefore 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 a sensor for a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF care. 
 
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 continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has been 
recovering in a SNF  after spinal fusion and laminectomy with CVA. From a nursing perspective, 
the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, 
the enrollee received physical therapy and occupational therapy in the SNF.  By the dates in question, the 
enrollee was at a stand by assist to contact guard assist level with functional mobility including gait to 75 feet 
with a rolling walker.  The enrollee required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implant services. 
 
You asked the Plan to pre-approve the dental services. You say that you are having trouble eating. The Plan 
denied your request. The Plan says the services are not covered 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. 
 
 The file shows that a surgical placement of implant body, prefabricated abutment, implant supported crown, 
bone graft, and guided tissue generation were requested. Although the Plan offers a dental benefit in excess of 
Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve dental implant services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostatic arterial embolization (PAE) procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you are a good candidate for success 
with the procedure. The Plan denied your request. The Plan says there is limited evidence-based research on the 
safety and efficacy of the procedure. 
 
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 requested services. Our physician 
reviewer found that you have a history of benign prostatic hyperplasia and retention of urine. Your urinary 
retention is being treated with Foley catheter, Finasteride, Tadalafil and Tamsulosin. Your most recent 
cystoscopy showed median lobe, obstructing prostate 5-6cm. Prostatic arterial embolization is considered an 
experimental minimally invasive surgical treatment for benign prostatic hypertrophy. There is limited 
evidenced on the safety and or efficacy of the procedure. Therefore, the services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prostatic arterial embolization (PAE) procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the member is not yet safe to return home. The Plan denied your request. The Plan says the member is 
receiving appropriate care in the inpatient rehabilitation facility. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member does not require skilled 
nursing or skilled therapy services on a daily basis in an SNF. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone tablets. 
 
You asked the Plan to pre-approve Prednisone tablets. You say that this is medically necessary. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D 
prescription drug 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 Prednisone tablets.  
 
Benefits for Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral knee genicular blocks. 
 
You asked the Plan to pre-approve bilateral knee genicular blocks. You say that the requested bilateral knee 
genicular blocks are medically necessary. The Plan denied your request. The Plan says the requested bilateral 
knee genicular blocks are not medically necessary. 
 
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 bilateral knee genicular blocks. Our 
reviewer says that the requested bilateral knee genicular blocks are not medically necessary. Our physician 
reviewer found this enrollee presents with complaints of chronic progressive bilateral knee pain. She reportedly 
wishes to avoid recommended bilateral total knee arthroplasties. She reports pain is worsened with prolonged 
walking. Clinical exam findings are reported consistent with radiographic evidence of moderate to severe 
tricompartmental bilateral knee osteoarthritis. She has failed to adequately improve with pain medications, 
steroid injections, and viscosupplementation. Under consideration is a request for bilateral knee genicular 
blocks. The requesting physician indicates that these blocks are requested to determine candidacy for 
radiofrequency ablation. There is a lack of large volume, long-term peer-reviewed outcome studies to support 
the use of these procedures for this enrollee as discussed above. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as the standard of care. 
Therefore, the requested bilateral knee genicular blocks are not medically reasonable and necessary for the 
enrollee 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 bilateral knee genicular blocks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bilateral knee genicular blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision of benign lesion up to 1.25 cm (D7410), 
therapeutic parenteral drugs, two or more administrations, different medications (D9612), deep 
sedation/general anesthesia - each subsequent 15 minute increment (D9223) and deep sedation/general 
anesthesia - first 15 minutes (D9222). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting the denial of a biopsy 
that could be possible cancer. 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 EOC or Dental Customer Handbook 
as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pre-
approve excision of benign lesion up to 1.25 cm (D7410), therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), deep sedation/general anesthesia - each subsequent 15 minute 
increment (D9223) and deep sedation/general anesthesia - first 15 minutes (D9222).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Lite Test Strip. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is a non-formulary request. 
 
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 test strips. Our reviewer says that 
the requested test strips is not considered medically reasonable and necessary in this case. Our physician 
reviewer found you were ordered a specific brand - Free Style Lite test strips. The reviewed records do not 
support this specific brand is required versus other test strips approved by the plan. Without the support of the 
documentation, medical necessity cannot be determined. 
 
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 test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Freestyle Lite Test Strip.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cardiogenomics test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the treating provider ordered the tests, or that the enrollee 
has any signs or symptoms to indicate the tests would be medically necessary. 
 
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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have any symptoms nor a diagnosis that would be identified or modified by this 
testing. Per the documentation, a call was placed to her provider's office on September 10, 2020, and the staff 
confirmed that she was last seen there in November 2019, and that she was listed as inactive with the office.  
 
The clinical notes from a visit there on November 26, 2019, indicated that she had a medical history which 
included hypertension, diabetes, and hyperlipidemia. At that time, she was complaining of ingrown toenails. 
Laboratory studies to evaluate renal and liver function, blood count and diabetes were reviewed. There was no 
indication of concern for hereditary cardiac conditions or that genetic testing was requested. The review has 
determined that the enrollee does not meet the criteria for this request. 
 
 
 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Cardiogenomics test for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Granix injection. 
 
You asked the Plan to pre-approve the requested services. You say that if the enrollee's while blood count 
continues to drop, she will be hospitalized. The Plan denied your request. The Plan says medical literature does 
not support Granix for the treatment of cytopenias in the setting of Hepatitis C. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve the requested services. Our physician 
reviewer found that the enrollee has a history of hepatitis C, pancytopenia likely due to cirrhosis and portal 
hypertension, and hypercellular bone marrow. The requested use of Granix is not FDA approved. It is not 
supported in any of the CMS approved compendia. There is no evidence of supporting citations in a PubMed 
search. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. The 
documentation does support 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Granix injection.