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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has completed his current 
stay, is stable for transfer, and exceeds the criteria for an LTACH admission. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for the LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interspinous device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's quality of life is severely 
reduced. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered. 
 
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 the Coflex device is experimental. More research is needed to show its safety and efficacy. 
Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Coflex interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair (K0861) and 
related accessories and features to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair with related accessories. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for OON 
care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a Group 3 standard power wheelchair (K0861) and related accessories and features to be provided by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the LTACH admission you requested does not meet 
Medicare guidelines. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently 
unstable for transfer to the LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable for transfer. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
 
 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs. 
 
 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 Ilumya. Our physician reviewer found 
that the enrollee has psoriasis vulgaris. The Plan requires a trial of Enbrel, Humira, Otezla, or Skyrizi before 
they will approve the requested drug. There is no indication that the enrollee has tried and failed the required 
drugs. There is no indication that the Plan's required drugs would likely be less effective or likely have adverse 
effects 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on March 28, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that your PCP advised you to go 
to urgent care for x-rays, but the facility did not do them. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for the urgent care visit. This item/service falls within the 
urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the urgent 
care visit provided on March 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the injections have significantly reduced the degree of 
scalp hyperhidrosis and the injections are medically necessary moving forward. The Plan denied your request. 
The Plan says the use of Botox for hyperhidrosis of the scalp is not FDA-approved. 
 
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 pre-approve Botox. Our reviewer says that the use 
of Botox is not FDA-approved for the enrollees diagnosis. Our physician reviewer found that Botox is only 
supported for use in axillary hyperhidrosis. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has tried and failed bi-level 
positive airway pressure (BiPAP) as outpatient and continued to be hypercapnic. You say that the requested 
noninvasive ventilator is beneficial to the enrollee's health and overall wellbeing. The Plan denied your request. 
The Plan says the request for a home mechanical ventilator in average volume-assured pressure support 
(AVAPS) mode with Auto-EPAP (AE) that could be delivered by bi-level positive airway pressure (BiPAP) is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was successfully treated with BiPAP.  The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020). 
 
You asked the Plan to pre-approve frames (V2020). You say that you are diabetic. You also say your specialist 
advised you to obtain new eyeglasses. The Plan denied your request. The Plan says you received an exam and 
elective contact lenses on July 20, 2021, so you are not eligible. The Plan also says that you will be eligible for 
new eyeglasses on July 1, 2023.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $300 for eyeglasses (frames and lenses) or contact lenses every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover up to $300 for eyeglasses (frames and 
lenses) or contact lenses every two years. The record shows that you purchased contact lenses on July 20, 2021. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve frames (V2020).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive lumbar decompression 
procedure (0275T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that you have been having ongoing back 
issues that restrict your day-to-day activities such as going to the grocery store and seeing your family. The 
Plan denied your request. The Plan says based on Medicare guidelines, you do not meet the criteria as the 
records do not show that you are in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve the minimally invasive lumbar decompression procedure (0275T).
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. The Plan denied your request. The Plan says the enrollee does not 
have complex care needs that require a coordinated team approach. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for a total hip replacement. Her medical problems are 
stable. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the service is considered medically 
necessary. The Plan denied your request. The Plan says there are no clinical indications for this request. 
 
The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins 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 documentation suffers from a lack of clarity. It noted that the enrollees issues appear to 
be in the left leg. However, it is not clear why the provider had scheduled the enrollee previously for right leg 
ablation. In the physical examination section, the enrollee is described as having both no lower extremity 
edema and moderate edema bilaterally.  It is unclear that the enrollee is having significant symptoms due to 
the varicose veins, although it is noted that she has severe knee pain due to arthritis. There is a notation that the 
left leg is asymptomatic. This may be a typo; however, it may also explain why the provider was initially 
planning on treating the right leg. It is also unclear if concerted efforts at conservative treatment were 
attempted. Lastly, it appears that the source of the reflux is in the enlarged and tortuous anterior accessory 
saphenous vein. It is noted that it joins the great saphenous vein in the distal thigh. However, it is not clear how 
ablation of the distal thigh great saphenous vein would impact the anterior accessory saphenous vein, 
particularly since a large portion of the great saphenous vein is normal. In summary, the coverage criteria have 
not been met and, the documentation lacks the clarity on which to override the determination on the basis of 
medical necessity.  
 
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 endovenous ablation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen. 
 
You asked the Plan to pre-approve hydrocodone-acetaminophen. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the requested drug is not covered under Medicare 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 hydrocodone-
acetaminophen.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that you cannot walk properly. The Plan denied your 
request. The Plan says you have not tried one of the preferred drugs. 
 
 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 Monovisc. Our physician reviewer 
found that you have bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc, 
Synvisc, or Synvisc One before they will approve the requested drug. In this case, you have not tried and failed 
the required drugs. There is no documentation provided indicating that the Plans required drugs would likely 
be less effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injection. 
 
You asked the Plan to pre-approve Synvisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 pre-approve Synvisc. Our reviewer says that the 
documentation does not support that the requested is medically reasonable or necessary. Our physician 
reviewer found the enrollee has knee pain and a diagnosis of osteoarthritis of both knees. She had bilateral 
Synvisc-One injections on May 24, 2022, which reportedly provided "minimal relief". Reuse of Synvisc-One 
when the prior treatment provided only minimal pain relief is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee 
does not meet criteria for the requested injection. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc injection.
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 IRF specializes in the care and treatment of 
medically complex patients, requiring intensive therapies PT, OT, and ST. Services required for the enrollee 
cannot be safely met with home health services or a SNF at this time. The Plan denied your request. The Plan 
says the request is not medically necessary, the services the enrollee needs can be provided safely in other 
settings, for example, a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level 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 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: 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 enrollee has been to inpatient rehabilitation and 
done very well. The Plan denied your request. The Plan says the enrollee is medically stable with a lack of 
medical complexity. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for back pain after a fall. His medical problems are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.