Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Liver allotransplantation (47135) and Renal allotransplantation (50365). 
 
You asked the Plan to pre-approve Liver allotransplantation (47135) and Renal allotransplantation (50365). 
You say that the requested Liver allotransplantation (47135) and Renal allotransplantation (50365) are 
medically necessary. The Plan denied your request. The Plan says that the requested Liver allotransplantation 
(47135) and Renal allotransplantation (50365) are not medically necessary. 
 
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 Liver allotransplantation (47135) and 
Renal allotransplantation (50365). Our reviewer says that the requested Liver allotransplantation (47135) and 
Renal allotransplantation (50365) are medically necessary. Our physician reviewer found the record indicates 
that the enrollee has alcoholic cirrhosis with manifestations of liver disease of edema, varices, and 
encephalopathy.  The record indicates that the enrollee has a MELD score of 17 as of March 2022 and has been 
sober as documented by ethyl glucuronide testing since 2020. The record indicates that the enrollee has stage 
IV kidney disease.  The record indicates that the enrollee has been approved by a clinic's kidney and liver 
transplant selection committee to be placed on the list at their center.  The enrollee satisfies its
listing criteria. The record provided establishes the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are satisfied. The requested 
service 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 Liver allotransplantation (47135) and Renal allotransplantation (50365) have 
been met. Therefore, we decided that the Plan has to pre-approve Liver allotransplantation (47135) and Renal 
allotransplantation (50365).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care to be 
provided by a network facility. 
 
 
 You asked the Plan to pre-approve the continued SNF care. You say that you feel like you are regressing. The 
Plan denied your request. The Plan says authorization denied because the continued SNF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do 
not have documented skilled therapy needs. You are ambulating more than 100 feet and tending to activities of 
daily living (ADLs) with minimal supervision. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 
be provided at a lower level of care (ex. home, AL, LTC). 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot (J9217). 
 
You asked the Plan to pre-approve Lupron Depot. You say that the enrollee was getting Vantas for prostate 
cancer and it is no longer available. You also say that your office utilizes Lupron Depot in its place, and it is 
the drug that you stock. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products. The enrollee has not tried any of the preferred agents. The Plan also 
says that the provider does not provide a rationale for use of the non-preferred product for safety or efficacy.  
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 Lupron Depot. Our reviewer says that 
Lupron Depot is not medically reasonable and necessary. Our physician reviewer found the provided records 
do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Eligard. Our 
reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J9217).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings will 
help to get the blood back to your heart and avoid more complications with edema and swelling. The Plan 
denied your request. The Plan says that this is a non-covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent injection 75mg/ml. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall 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 Praluent injection 75mg/ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you had to have a front tooth pulled, and your current denture cannot be fixed to have a tooth added. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial denture (D5213) is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on June 17, 2019 and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cimzia Prefilled Kit 200mg/ml for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is self-injected. 
 
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 a Cimzia Prefilled Kit 
200mg/ml for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record provided does not indicate that the requested hospital stay is 
associated with a scheduled procedure that is already authorized. The elements of the coverage rule are not 
satisfied. The requested service is not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says this 
request is not medically necessary. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. Our reviewer found that there are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. Our 
physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition you have and able to be furnished safely and effectively only on an 
inpatient basis. 
 
 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says authorization denied because LTACH is not medically necessary and 
the enrollee's needs can be met at a lower level of care such as an acute rehabilitation facility, skilled nursing 
facility, outpatient setting, or home care. 
 
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 is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where 
he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that 
are not available at the health care setting being offered by the health plan. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the knee. 
 
You asked the Plan to pre-approve the RFA of the knee. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says this type of procedure is not 
recommended for the treatment of diabetic neuropathy. 
 
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 RFA of the knee. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. 
 
 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 RFA of the knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA) of the knee.
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 is appropriate for the facility and is able 
to participate in extensive rehabilitation. The Plan denied your request. The Plan says criteria for admission to 
the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided 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 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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have any parental 
medications, complex wound care or nutrition given via a feeding tube. You received skilled care and 
improved; however, your functional improvement had plateaued by 3/25/22 and you did not require any further 
inpatient skilled rehab services. Your function was at or near your prior level of function and you could be 
discharged to a lower level of care for further services. As of 3/25/22, you required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any 
parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled 
care and improved; however, her functional improvement had plateaued by 4/9/22 and she did not require any 
further inpatient skilled rehab services. The enrollees function was at or near her prior level of function and 
she could be discharged to a lower level of care for further services. As of 4/9/22 the enrollee required 
custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional direct skilled nursing services of a 
registered nurse (RN) (G0299 x3). 
 
You asked the Plan to pre-approve the additional direct skilled nursing services of a RN. The Plan denied your 
request. The Plan says the requested care is for convenience and does not meet criteria. 
 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care 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 additional direct skilled nursing 
services of a RN. Our reviewer says that the requested home health skilled nursing services are not medically 
necessary or reasonable. Our physician reviewer found you do not have currently documented skilled nursing 
needs. 
 
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 additional direct skilled nursing services of a RN have not been met. 
Therefore, we decided that the Plan does not have to pre-approve three additional direct skilled nursing services 
of a registered nurse (RN) (G0299 x3).