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

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that you do not have a meniscus tear. You also say that 
you have arthritis. The Plan denied your request. The Plan says you have not tried and failed any of the 
preferred drugs, Orthovisc, Synvisc, or Synvisc-One. 
 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. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that you have tried and failed at least one of the step one alternatives, Orthovisc, Synvisc, or Synvisc-
One. The reviewer also found that the documentation does not outline contraindications or reasons these 
medications were not considered or that the plan's additional required drugs would likely be less effective 
and/or likely have adverse effects for you. Therefore, the reviewer found that the step therapy 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics (L3000). 
 
You asked the Plan to pre-approve custom foot orthotics. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit for the 
enrollees condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for her, neither Medicare nor the Plan provides coverage of this item for 
her condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3000).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve proton treatment delivery (77523). 
 
You asked the Plan to pre-approve proton treatment delivery. You say that proton therapy has been proven safe 
and effective for prostate cancer and these services are necessary. The Plan denied your request. The Plan says 
that these services are not medically necessary as they are not indicated for the treatment of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 proton treatment delivery. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the National Comprehensive Cancer Network (NCCN) Panel believes there is no 
clear evidence to support a benefit or decrement to proton therapy over Intensity-modulated radiation therapy 
(IMRT) for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy 
can be considered a reasonable alternative to x-raybased regimens at clinics with appropriate technology, 
physics, and clinical expertise. Therefore, these services are reasonable and necessary as they are not inferior to 
other options for the enrollee's cancer. 
 
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 treatment delivery have been met. Therefore, we decided that the Plan 
has to pre-approve proton treatment delivery (77523).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 
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 Dronabinol.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white cane. 
 
You asked the Plan to pre-approve the cane. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a white cane.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), spinal canal and 
contents (72158). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically necessary. Our physician reviewer found the record provided does not indicate 
the presence of any red flag symptoms or neurological examination abnormalities. The record does not indicate 
the failure of conservative therapy. The record indicates that the enrollee now has back pain. Therefore, the 
reviewer found that the requested MRI is not medically necessary and reasonable. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI), spinal canal and contents (72158).
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 meets the Medicare criteria for inpatient 
rehabilitation. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 there is no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain his functional status.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis 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 Restasis 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 enrollee is medically stable and does not need physician's supervision 3 times a 
week in an IRF. Based upon the current level of function, the enrollee will not make a significant functional 
recovery in a predicted period of time in an IRF especially at base line, the enrollee was not functional. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with a multidisciplinary approach to rehabilitation care. While the enrollee may 
benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an 
alternate and lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve 12 physical therapy visits. 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 medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 12 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have made some progress in terms of improved cervical spine range of motion and motor strength remains unchanged. You would benefit from continued physical therapy 
and the total of 24 sessions of physical therapy should suffice for continued potential improvement and 
transitioning to a home exercise program. If additional therapy is warranted, then a re-revaluation should be 
provided indicating the need for continued therapy. Therefore, the 12 visits of additional therapy cannot be 
considered 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 12 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton therapy (IMRT) (77523). 
 
You asked the Plan to pre-approve Proton therapy. You say that it is medically necessary. The Plan denied your 
request. The Plan says the requested therapy does not meet the requirements for approval. 
 
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 therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the proton beam therapy is not being furnished in accordance with accepted standards of 
medical practice for the diagnosis or treatment of the enrollee's condition or to improve the function of a 
malformed body member. It is not clear that this therapy is at least as beneficial as an existing and available 
medically appropriately. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Proton therapy (IMRT) (77523).
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 your health is decreasing and is not getting adequate 
care. You say you need the rehabilitation. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you have not had a change in your baseline medical conditions after admission to the skilled nursing facility and therefore would not require the oversight of a rehabilitation physician in the acute 
inpatient rehabilitation setting. You do not require rehabilitation nursing care, including complex wound care, 
tracheostomy management, or management of parental nutrition or tube feeding. Your medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Space Oar insertion to be provided in an outpatient 
setting. 
 
You asked the Plan to pre-approve Space Oar insertion. You say that the enrollee is considered to be high risk. 
You also say that the requested procedure is medically necessary. The Plan denied your request. The Plan says 
the documentation shows that the prostate volume is estimated to be 83 cc. The Plan also says that this is a 
direct exclusion of coverage for this procedure. 
 
The Plan follows Medicare rules. Medicare rules say that polyethylene-glycol (PEG) hydrogel is covered once 
in patients with clinically localized prostate cancer with all of the inclusion criteria and none of the exclusion 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Space Oar insertion have not been met. Specifically, the file indicates that the 
prostate volume is more than 80 cc. Therefore, we decided that the Plan does not have to pre-approve Space 
Oar insertion to be provided in an outpatient setting.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA is covered when the enrollee has received two 
medically reasonable and necessary diagnostic medial branch blocks, with each one providing a consistent 
minimum of 80% sustained relief of primary (index) pain. 
 
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 RFA. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain. The low back pain is made worse with 
activity. The enrollee is status post two diagnostic median branch blocks performed, each with a 50% 
improvement in pain relief. The documentation does not support that the enrollee had medial branch blocks 
with a minimum of 80% sustained relief of primary (index) pain. Therefore, the enrollee does not meet criteria 
for the requested 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve facet joint radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has been treated with Prolia since 2013 
with reported clinical response and absence of fractures. The Plan denied your request. The Plan says the 
enrollee does not have a pharmacy benefit under this contract. 
 
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 Prolia.  
 
Benefits for Prolia 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 a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve a repeat injection. You say that the enrollee is constantly in severe pain. 
You also say that without the injection, they will not be able to move around freely without pain. The Plan 
denied your request. The Plan says the criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injection (ESI) may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using the same scale for at 
least three months. 
 
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 repeat injection. Our reviewer says 
that the requested repeat injection is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate at least 50% of sustained improvement in pain relief and/or improvement in 
function measured from baseline using the same scale for at least three months. Therefore, the reviewer found 
that the criteria for coverage 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 a repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the enrollee has had a continuous cough for over 
six months and is unable to have chest compression done at home 
because the enrollee is too fragile. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
 The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device (HFCWOD).