Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for lumbar fusion. She is now medically stable with no complex nursing or rehabilitation needs. She
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy,
there is no documentation of a need for an intensive 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: 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 you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 improving but still is still unstable and should only require short-term
additional acute care services. These can be provided at the current facility until discharge to a lower level of
care is appropriate.
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 lumbar epidural steroid injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says imaging
does not show a pathology that supports the requested procedure.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under
certain medical indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician
reviewer found that the enrollee has chronic low back pain with radiation into her legs. She last had physical
therapy in 2016. Her magnetic resonance imaging (MRI) shows neuroforaminal stenosis at L1/L2 and L2/L3
and severe facet arthropathy at L4/L5 and L5/S1. She had a prior ESI which gave her 50% pain relief for 4
weeks. The request is to repeat the ESI. There is no recent trial of conservative therapy such as physical therapy
or chiropractic care. The MRI does not demonstrate disc herniations or other indication for epidural steroid
injection. The request does not meet the criteria with respect to failed trial of conservative therapy and the
imaging does not identify pain generators that are amenable to epidural steroid injections. Therefore, the
request 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve lumbar epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee does not have a medically necessary condition.
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 enrollee has neuropathic pain for which he is taking Buprenorphine, Tizanidine and
Dronabinol. He has an intra-thecal pump catheter in place as well as a spinal cord stimulator (SCS) where the
generator was changed to burst mode, but the enrollee did not achieve any better pain relief. A psychological
evaluation cleared him for additional spinal cord stimulation. The request is to place the leads at the level of
T12 and L3 which are below the coverage of the hip. There is no documentation of the various intra-thecal
medications trials which could cover both lower extremities. There is no documentation of the re-programming
attempts. The request for lead placement is below the terminus of the spinal cord. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve spinal cord stimulation.
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 transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee is receiving the appropriate care in the current facility and does not have
clinical conditions that cannot be adequately treated in the current hospital. There are no issues for which an
LTACH may offer a therapeutic advantage.
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 record indicates that the enrollee is improving but still requires acute care
services. The enrollee is receiving acute care services at the current facility, and these have not been denied.
The record does not indicate that the enrollee requires services that they are 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba FlexTouch injection services.
You asked the Plan to pre-approve Tresiba. You say that the enrollee uses 18 units of Tresiba daily, along
acting insulin analog. You say that the enrollee also uses Ozempic 1mg injection once a week. You say that the
enrollee's home glucose numbers are usually around 130 and that his last A1C was around 7. You say that the
records support the need for the requested drug. The Plan denied your request. The Plan says , since the
medication will not be provided incidental to the physician visit it is not covered under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tresiba FlexTouch injection
services.
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 SNF care is medically necessary for your condition.
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 that you do not require skilled nursing services
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively
provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence
of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your high functional level
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a
SNF. As a practical matter, you do not require the necessary services on 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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 4mg Ondansetron tablets.
You asked the Plan to pre-approve the Ondansetron tablets. You say that you would like reconsideration because 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 the 4mg Ondansetron tablets.
Benefits for the Ondansetron tablets 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 second opinion visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve orthopedic visit. You say that the nature of your condition is causing spine and back problems and pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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 second opinion visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after February 10, 2022.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically
reasonable and necessary. The Plan denied your request. The Plan says the criteria for SNF care are no longer
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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found that the
documentation does not reveal evidence of ongoing complex wound care, new enteral feedings, or other skilled
nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and
reasonable treatment in a SNF beyond the last covered date. Your cognitive status appears to be a significant
barrier in therapy and limiting effective carryover. You do not require skilled nursing or skilled therapy
services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not
require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered
date.
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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after February 10,
2022.
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 you need inpatient rehabilitation services. The Plan
denied your request. The Plan says the criteria for admission to an IRF are not met. You can receive the
services you need in 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 your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) (E0601).
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan
denied your request. The Plan says the device was not used greater than or equal to 4 hours per night on 70% of
nights during a consecutive thirty (30) day period.
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP
greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime
during the first three (3) months of initial usage.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous positive airway pressure (CPAP) (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro motion assist device (L8702).
You asked the Plan to pre-approve a MyoPro device. You say that the requested item is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested item is 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 a MyoPro device. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that no records from the enrollee's treating provider explain the rationale for the requested
device and why the MyoPro motion assist device is the most appropriate treatment for the enrollee's condition.
The only medical records indicating a need for the device are records from the device vendor. The device order
is not considered part of the supporting medical record. In addition, the requested device is of unproven long-
term benefit in the home environment.
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 MyoPro device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a MyoPro motion assist device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says the enrollee is not suffering from active venous stasis ulcers, or
any burn and/or recent surgical wound that need compression garment to secure dressings.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia.
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the
required drugs would be contraindicated or less effective; therefore, Feraheme is not reasonable or medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Feraheme.
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 transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH
would add no additional services. With more time in the current setting, clinical stability can be ensured such
that the appropriate lower level of care can be determined.
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 record indicates that the enrollee requires ongoing acute care services as she
remains comatose and unable to be weaned from mechanical ventilation. 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 they are 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.