Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve these services. You say that your doctor recommended the drug. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia. 

Benefits for these services 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 hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is to increase oxygen delivery 
to the tissues, reduce edema, and prevent further morbidity. The Plan denied your request. The Plan says there 
is no documentation of optimization of circulation, or treatment of any underlying infection. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has type II diabetes, and a Wagner stage 3 wound of the left medial malleolus 
measuring 0.5 cm x 0.5 cm x 0.2 cm on July 2, 2020. He has been treated with antibiotics for cellulitis and has 
had revascularization of the left leg. There are no measurements or photo documentation of the wound included 
for the visit on August 6, 2020. The record does not document a failure to respond to revascularization. The 
records do not show that the enrollee has a covered indication for the requested therapy. Therefore, the 
requested therapy is not medically reasonable and necessary to treat the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy (77499). 
 
You asked the Plan to pre-approve 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it is unclear if the enrollee has been receiving systemic therapy (the records do not 
specify) and if systemic therapy is not being administered, the records do not specify why systemic therapy is 
not being considered. There are also no records of a positron emission tomography/computed tomography 
(PET/CT) scan being performed (which was explicitly requested by the insurer to establish necessity). It does 
not appear that the proposed treatment is furnished in accordance with accepted standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy (77499).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, lumbar; without 
contrast material (72148), for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that a cervical spine MRI was meant to be ordered. The 
Plan denied your request. The Plan says the provider requested the wrong test. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. The request for lumbar spine MRI was 
erroneous and not required by the member and it was confirmed by the provider's office. The provider's office 
stated that they will be submitting a new Prior Authorization request for cervical spine MRI which is what they 
intended to order. Therefore, we decided that the Plan does not have to pre-approve the MRI, spinal canal and 
contents, lumbar; without contrast material (72148), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25mg Myrbetriq tablets. 
 
You asked the Plan to pre-approve the Myrbetriq. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says Myrbetriq Tab 25mg falls under Part 
D coverage, but member has no Part D pharmacy 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 25mg Myrbetriq tablets.  
 
Benefits for the Myrbetriq 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: 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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Although the record supports the need for physical and occupational therapy 
services, it does not support a need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic polysomnography (PSG) sleep testing. 
 
You asked the Plan to pre-approve the PSG sleep testing services. You say that the records provided support 
the need for a sleep study. The Plan denied your request. The Plan says evidence has not been provided 
indicating clearly that the enrollee may suffer from OSA. The Plan says that the enrollee's current complaint is 
that of coughing and wheezing and she has a 35 pack year smoking history. The Plan says that the LCD states 
that testing is not covered to diagnose chronic lung disease. The Plan says that the enrollee's complaints are 
either about chronic lung disease or some type of reactive lung disease. The Plan says that there is no sleep 
history provided and the records do not mention that the enrollee snores or has had witness apnic spells. 
 
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 PSG sleep testing services. Our 
reviewer says that diagnostic PSG sleep testing is not considered medically reasonable and necessary in this 
case. Our physician reviewer found a clinic visit on June 24, 2020 noted dyspnea, wheezing, and nocturnal 
hypoxemia. It also noted cirrhosis of the liver with ascites and chronic prescription opiate use. There was no 
detailed sleep history or detailed upper airway exam. There was no neck circumference. A review of the 
enrollee's symptoms were positive for snoring and the enrollee's score is normal at 7. 
 
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 PSG sleep testing services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve diagnostic polysomnography (PSG) sleep testing.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has had success with the Prolia injections. 
The Plan denied your request. The Plan says that Prolia does not meet the Plan's criteria for coverage. 
 
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. Our reviewer says that Prolia is 
medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has been using 
Prolia since 2014. Step-therapy criteria do not apply, as this is not a new prescription. The enrollee does not 
have a contraindication to the requested drug and meets criteria for approval. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia (J0897).  
 
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 Prolia. 
 
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 Prolia is 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 services are not medically necessary. Our physician reviewer found the enrollee has osteopenia confirmed 
on DEXA scan. A DEXA scan is currently the criterion standard for the evaluation of bone mineral density 
(BMD) and has been shown to be the best indicator of fracture risk. The records do not support that the enrollee 
meets the criteria for coverage of Prolia and the requested drug is 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 Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a high risk of skin breakdown and
without the rehab, her physical deconditioning could worsen. The Plan denied your request. The Plan says that
the enrollee does not need daily skilled nursing services to monitor and assess issues.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafting for the maxillary and mandible areas, 
Alveoloplasty, impression and preparation for both an oral splint and interim obturator, panoramic jaw 
imaging, and related anesthesia. 
 
You asked the Plan to pre-approve the oral surgery services. You say that these services are necessary. The 
Plan denied your request. The Plan says the services are dental in nature and excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also indicate that services involving the care, treatment, filling, removal or 
replacement of teeth or structures directly supporting the teeth are excluded from Medicare coverage. The 
contract provides no extra benefit which would cover these services. 
 
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 oral surgery services. Our reviewer 
says that the documentation does not support that the services are requested for treatment of a medical 
condition. Our physician reviewer found A review of the patient's dental record and radiographs indicate the 
treatment is to prepare the ridges to support dental prostheses. The procedures indicated are to treat the 
supporting structures (alveolar processes) which are directly related to support the dental prostheses 
(teeth).  These procedures meet the definition of dental services which are not covered by Medicare, and are 
not a covered supplemental benefit. 
 
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 oral surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone grafting for the maxillary and mandible areas, Alveoloplasty, impression 
and preparation for both an oral splint and interim obturator, panoramic jaw imaging, and related anesthesia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Ondansetron for the 
enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ENTRESTO for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 ENTRESTO for the 
enrollee.  
 
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute medical care and extensive 
rehab so he can return to his home setting. You say that the longer he waits for rehab, the longer it will take to 
return to baseline. The Plan denied your request. The Plan says the criteria for coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the enrollee's functional status or endurance 
level requires an intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture with electrical stimulation provided from
February 28, 2020 to March 12, 2020.
You asked the Plan to pay for acupuncture with electrical stimulation. You say that the provider told you it
would be $20 per session. The Plan denied your request. The Plan says acupuncture is no covered under your
Plan contract.
The Plan must follow Medicare rules. The rules say Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements. We looked at the file and Medicare rules. Based on this
information, we decided that the rules for coverage of the acupuncture with electrical stimulation are not met.
Specifically, the Plan does not cover acupuncture of any type and Medicare only covers limited acupuncture
services for a specific diagnosis. Therefore, we decided that the Plan does not have to pay for acupuncture with
electrical stimulation provided from February 28, 2020 to March 12, 2020.