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

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative, zoledronic acid. 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. 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 Prolia have not been met. Specifically, the file does not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. Therefore, we decided that the Plan does 
not have to pre-approve Prolia (J0897).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer from an inpatient rehabilitation facility to a 
skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require skilled nursing services as the records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. While you do require 
skilled therapy services, these services are not required on a daily basis. In conclusion, there is no 
documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in a long-term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transfer from an inpatient rehabilitation facility to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Bronchoscopy (31624) provided on July 18, 2021. 
 
You asked the Plan to pay for code 31624. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The Bronchoscopy in question was provided within the 90-day global 
period for the surgical procedure (code 43117) that was provided on July 13, 2021. This means that payment 
for the Bronchoscopy was included in the payment for the surgical procedure. Based on this information, we 
decided that Medicare rules for coverage of code 31624 have not been met. Therefore, we decided that the Plan 
does not have to pay for the Bronchoscopy (31624) provided on July 18, 2021.
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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the rules for IRF care have 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 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. The 
review indicates that the enrollee is an 86 yo female with a medical history which includes diabetes, atrial 
fibrillation, heart failure, and neuropathy.  She presented to the hospital with poor oral intake and uncontrolled atrial fibrillation. Her medical conditions 
have stabilized, and she is working with therapy to improve her abilities. Our physician reviewer found the 
review has determined that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis (J7322). 
 
You asked the Plan to pre-approve Hymovis. You say that you would like the Plan to reconsider allowing you 
to have the injection and not make you wait another 3 months. The Plan denied your request. The Plan says you 
do not meet the prior authorization criteria rules for Hymovis. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the 
patient has failed at least three months of conservative therapy and the patient has failed to respond to 
aspiration of the knee. 
 
 
  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 Hymovis. Our reviewer says that you 
do not meet the coverage criteria for Hymovis. Our physician reviewer found you have not completed non-
medication therapy as ordered. Your provider has recommended physical therapy, but you declined the 
services. Our reviewer found that there is no documentation of a 3-month trial of simple analgesics and non-
medication therapy. Our physician reviewer also found that although the review has determined that you are 
symptomatic, and the diagnosis is supported by radiologic evidence, you have not failed at least 3 months of 
conservative therapy and have. not failed to respond to aspiration of the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis (J7322).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee had a stroke and was supposed to get 
SNF treatment in order to return to prior level of functioning as he is unable to care for himself. You say that 
you request approval as he has no one to help him and he still needs assistance. The Plan denied your request. 
The Plan says the records show that all the services the enrollee requires are offered at the IRF. 
  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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing 
service needs. Our reviewer says that there are identifiable skilled therapy service needs but they are not 
required on a daily basis The enrollee does not meet the severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have Alzheimer's and need 24-hour assistance. 
The Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
  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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing 
service needs. Our reviewer says that there are identifiable skilled therapy service needs but they are not 
required on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the patient requires skilled nursing services as the records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. While this patient 
does require skilled therapy services, there is no documentation that daily skilled services are required. The 
patient is walking household distances with a rolling walker with contact guard assistance and is stand-by assist 
for transfers. In conclusion, there is no documentation that the patient requires the services on an inpatient 
basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term 
care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this is a medically 
necessary procedure. The Plan denied your request. The Plan says the diagnosed spinal cord compression 
contradicts the requested epidural steroid injection services. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections should be performed in 
conjunction with conservative treatments. 
 
 
  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 epidural steroid injection services. Our 
reviewer says that the requested epidural steroid injection services do not satisfy the Medicare coverage 
criteria. Our physician reviewer found that the enrollee is a 73-year-old woman who has chronic low back pain. 
She takes Lyrica for pain and received a Toradol injection. She received trigger point injections. Her magnetic 
resonance imaging shows multi-level spinal stenosis and degenerative changes. There is no documentation of 
physical therapy or a reason why it cannot be performed.  There is no documentation of other conservative 
therapies such as Chiropractic care. The request is for a caudal epidural steroid injection. There is no 
documentation as to other conservative therapies as being performed. Therefore, the request does not meet the 
LCD and the request is considered not medically reasonable or 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 epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits 7 days per week for 9 weeks, and 
home health aide visits 3 hours per day, 7 days per week, for 9 weeks. 
 You asked the Plan to pre-approve the home health services. You say that the HM service does your shopping. 
You say that you are still in pain from your hip surgery. You also say that this service is very important. The 
Plan denied your request. The Plan says you do not require any skilled care. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
provided documentation does not indicate that you have documented skilled nursing needs (i.e. IVs, complex 
wound care, new ostomy, new TFs). Therefore, the reviewer found that the requested home health services are 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits 7 days per week for 9 weeks, and home health aide visits 3 
hours per day, 7 days per week, for 9 weeks.
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 LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that in this case the enrollee was admitted with respiratory failure following recent 
discharge for COVID-19 pneumonia and has had a prolonged hospital course including acute kidney injury.   
 
 The record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. The 
elements of the coverage rules 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve a cervical spinal cord stimulator. You say that this is medically reasonable 
for your condition. The Plan denied your request. The Plan says the criteria for coverage of this device have not 
been met as it is not the last resort at this time. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are subject to the criteria 
listed 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 a cervical spinal cord stimulator. Our reviewer says that this requested item is not medically reasonable and necessary. Our physician reviewer found 
that this 61-year-old woman has chronic neck pain with radicular symptoms after a cervical spinal fusion. The 
request is for a cervical SCS. She has a functioning lumbar SCS in place.  There is no documentation of a 
neurosurgical consultation, recent physical therapy of the cervical regional or any new medication trials. There 
is no documentation of a neurosurgical consultation, recent physical therapy of the cervical regional or any new 
medication trials.  The request does not meet the criteria of the LCD and NCD and therefore, the request is 
deemed not medically reasonable and 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 a cervical spinal cord stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a cervical spinal cord stimulator (SCS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve amniotic fluid injection. 
 
You asked the Plan to pre-approve amniotic fluid injection. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested injection services are 
considered experimental/investigational. 
 
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 amniotic fluid injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is an 83-year-old female being treated for osteophyte right knee; 
knee pain; knee osteoarthritis. She presented with right knee pain. Her right knee pain has been ongoing pain 
for several years, but she has been able to manage conservatively. Her pain is episodic in nature but does admit 
to more medial sided pain with prolonged activities. 
 
In this case, there  is limited published, large-scale, long-term peer-reviewed literature that shows this request 
to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the request for amniotic fluid injection is not medically reasonable or 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 amniotic fluid injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve amniotic fluid injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable neurostimulator. 
 
You asked the Plan to pre-approve the implantable neurostimulator. The Plan denied your request. The Plan 
says the 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 the implantable neurostimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of 
recent, reasonable, and comprehensive less invasive conservative care measures. Detailed documentation is not 
evident that this would be a last resort option as detailed conservative care measures have not been trialed and 
failed. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the member does not meet the NCD coverage 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 the implantable neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the implantable neurostimulator.