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

 
We decided that the Plan does not have to pre-approve inpatient level of care for back surgery. 
 
You asked the Plan to pre-approve inpatient level of care for back surgery. 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. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient level of care for back surgery have not been met. Specifically, medical records were not 
provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided 
that the Plan does not have to pre-approve inpatient level of care for back surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time as the patient did not have dangerousness to self or others, auditory or 
visual hallucinations, delusions and was not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as the patient did not have dangerousness to self or others, perceptual disturbance including 
delusions, auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears 
appropriate. This patient did not appear to require inpatient mental health treatment as they were not a danger 
to themselves or others and was cooperative and compliant. It did not appear that active treatment was taking 
place. It did not appear that the services were reasonably expected to improve the patient's condition or for the 
purpose of diagnosis. Our physician reviewer was unable to find an individualized treatment plan however the 
entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based 
upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient 
mental health treatment as this patient was not shown to be a danger to themselves or others but was without 
agitation or aggression without perceptual disturbance including auditory, visual hallucinations or delusions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. 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 proton beam radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of proton therapy to a moderate dose of 45 Gy is not supported in 
the literature or the appeal. Proton therapy for prostate cancer is not experimental, and in fact is an accepted 
treatment approach. However, any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) for routine cases is investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
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 unilateral primary 
osteoarthritis of the left knee. He has not tried the Plan's required drugs of Orthovisc and Monovisc. The 
records do not support that the required drugs are contraindicated or less effective; therefore, the 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane (J7318). 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 Orthovisc and 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 Durolane (J7318). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not 
trialed one viscosupplemental treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires that one of these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Durolane 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 Durolane (J7318) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Durolane.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda (J9271). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the continued use of this drug requires no disease progression 
while on treatment. 
 
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 Keytruda (J9271). Our reviewer says 
that the drug is not reasonable and medically necessary. Our physician reviewer found the requested use is not 
supported in any of the CMS approved compendia or the FDA label. This reviewer did not find any supportive 
citations in a search. The enrollee has had progression of the cancer while on the drug and therefore it 
is not effective for him. The documentation does not support that the drug is medically reasonable and 
necessary, or 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 Keytruda (J9271) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Keytruda.
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 provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the necessary services can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 
additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) 
and/or redistribution and/or rest reinjection (CPT Code 78452). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not 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 service. Our physician reviewer 
found the patient has symptoms of shortness of breath and is in the age range for coronary artery disease 
(CAD) so is at least intermediate probability for the presence of CAD. These symptoms may be an anginal 
equivalent and atypical symptoms can be especially common in females. Although a prior scan was normal in 
the distant past, the patient has not had an ischemic evaluation in over a decade. The scan is medically 
necessary and the patient meets the Medicare LCD criteria for radionuclide testing. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or 
quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when 
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest 
reinjection (CPT Code 78452).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show worsening pain. 
 
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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the age of the fracture is not known. There is no evidence of a new fracture. Recent literature shows that 
kyphoplasty doesn't work. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve autologous peripheral stem cell transplant services with 
an out of network provider. 
 
You asked the Plan to pre-approve autologous peripheral stem cell transplant services with an out of network 
provider. You say that there are no options for stem cell transplant. The Plan denied your request. 
The Plan says the services being requested are available in network. 
 
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 
autologous peripheral stem cell transplant services with an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nitro rollator walker for the enrollee. 
 
You asked the Plan to pay for the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a gait trainer that is not coded correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
As this walker is coded with HCPCS E1399, it is not coded correctly. Based on this information, we decided 
that Medicare rules for coverage of the walker have not been met. Therefore, we decided that the Plan does not 
have to pay for a nitro rollator walker for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that transfer to an LTACH would add no additional services. 
 
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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for complications related to advanced 
dementia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport to outpatient therapy. 
 
You asked the Plan to pre-approve the ambulance transport services. You say that the enrollee has a spinal cord 
injury and cannot stand, pivot, or transfer. You say that the enrollee requires transportation to get to outpatient 
therapy. The Plan denied your request. The Plan says transportation from the enrollee's home to outpatient 
therapy is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. An outpatient therapy office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to an outpatient therapy 
office. Therefore, we decided that the Plan does not have to pre-approve ambulance transport to outpatient 
therapy.
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. The Plan denied your request. The Plan says services can be 
received at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no complex nursing or rehabilitation needs. Our reviewer says that the 
medical records support a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided, daily 
skilled services are not required. The enrollee does not require the services on an inpatient basis, in a skilled 
nursing facility setting. Services in the long-term care facility on a part time, as-needed basis appears 
appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the enrollee is ready for discharge. You say that you 
are requesting pre-approval for an IRF admission. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support a need for an intensive therapy program at 
the current functional level. Our reviewer says that the enrollee's rehab needs can be met at an alternate, low 
intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.