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

 
We decided that the Plan does not have to pre-approve Evenity (J3111) and the associated injection (96372). 
 
You asked the Plan to pre-approve Evenity and the associated injection. The Plan denied your request. The 
Plan says you do not have any stated contraindications to the preferred products, nor have you 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 Evenity and the associated injection. 
Our reviewer says that Evenity is not medically reasonable and necessary. Our physician reviewer found the 
provided records do not indicate that you have tried and failed the plan's preferred step one alternative, Forteo. 
Our reviewer found that the record does not indicate that you have 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 Evenity and the associated injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Evenity (J3111) and the associated injection (96372).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. There are no 
services at the LTACH that the enrollee requires that are not available in the health care setting being offered 
by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary due to 
your recent hospitalization.  You also say you are weak and at a risk for falls. The Plan denied your request. 
The Plan says SNF admission is not medically necessary because you can be managed 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing 
needs.  While you do have skilled therapy service needs, you do not require these services on a daily basis in an 
inpatient SNF 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does 
not meet the health conditions for this stay. 
 
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 services. Our physician reviewer 
found that the enrollee presented to the acute hospital with epigastric/chest pain with nausea and vomiting. The 
records do not document the need for intravenous medications, new tube feeding, or ostomy care or daily 
complex wound care. He is walking household distances with standby to supervision assistance and is modified 
independent for transfers. The provided records do not document a significant decline in his functional status to 
necessitate daily inpatient skilled therapy services. There is no documentation that he requires the services on 
an inpatient basis, only 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraluminal gastrointestinal tract imaging (91110). 
 
You asked the Plan to pre-approve intraluminal gastrointestinal tract imaging. You say that this procedure is 
medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the 
requested intraluminal gastrointestinal tract imaging is not medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that intraluminal gastrointestinal tract imaging is 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 intraluminal gastrointestinal tract 
imaging. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our 
physician reviewer found that capsule endoscopy is appropriate when clinical criteria raise reasonable concern 
for small bowel Crohn's disease. In this case, the evaluation for Crohn's has proved negative--e.g., both 
radiologically and histologically. There is neither lab evidence, as presented, for active inflammation nor 
malnutrition. The enrollee is undeniably underweight, but her test results suggest rapid gut transit likely 
reflecting her bowel resection in treatment for chronic constipation. Capsule endoscopy at this time is neither 
appropriate nor medically necessary. In fact, given her demonstrated rapid gut transit it is unlikely that the 
study, were it to be performed, would yield much clinical value. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraluminal gastrointestinal tract imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intraluminal gastrointestinal tract imaging (91110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter. 
 
You asked the Plan to pre-approve a scooter. 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that you have a personal mobility deficit that impairs participation in mobility related 
activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the 
home. The device is being requested for use in "shopping malls and Disney parks." There is no documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual 
wheelchair. You are reportedly using a cane presently. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter.
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 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 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azathioprine. 
 You asked the Plan to pre-approve Azathioprine. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not received a transplant. The enrollee's plan does not have a 
Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs 
do not meet the criteria for coverage. 
 
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 Azathioprine.  
 
Benefits for Azathioprine 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 repeat epidural steroid injections (64484, 64483). 
 
You asked the Plan to pre-approve the injections. You say that the service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that injections are covered when there is pain duration of 
at least four (4) weeks, and the inability to tolerate non-invasive conservative care or medical documentation of 
failure to respond to four (4) weeks of noninvasive conservative care. 
 
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 injections. Our reviewer says that 
the repeat injections are not medically necessary. Our physician reviewer found other than pharmacotherapy, 
there is no indication from the records submitted of current use of physical therapy (PT), spinal manipulation 
therapy, cognitive behavioral therapy, or home exercise program for the enrollee's symptoms. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (64484, 64483).
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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. Our 
physician reviewer found 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: 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 a need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You are walking 
household distances with a rolling walker with contact guard assistance and is contact guard assist for transfers. 
Provided records do not document a significant decline in your functional status to necessitate further daily 
inpatient skilled therapy services. You do not require 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (64483, 64484). 
 
You asked the Plan to pre-approve the repeat epidural steroid injections. You say that the repeat injection is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections are indicated when 
the first ESI directly and significantly provided improvement of the condition being treated 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 3 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 the repeat epidural steroid injections. 
Our reviewer says that the repeat injections are not medically necessary. Our physician reviewer found there is 
no documentation of the percentage of improvement form the injection that was performed on April 22, 2022. 
 
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 repeat epidural steroid injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve repeat epidural steroid injections (64483, 64484).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 
You asked the Plan to pre-approve Genvisc 850. 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. 
 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 Genvisc 850. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, you have not tried and failed 
the required drug(s). There is no documentation provided indicating that the plans required drug(s) likely be 
less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Genvisc 850.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve preoperative stereotactic body radiation therapy (SBRT) 
to the right humeral lesion. 
 
You asked the Plan to pre-approve preoperative SBRT to the right humeral lesion. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have 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 preoperative SBRT to the right humeral 
lesion. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found more standard forms of radiation therapy could be offered 
and expected to yield acceptable control of these metastases. SBRT would not be considered to be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of preoperative SBRT to the right humeral lesion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve preoperative stereotactic body radiation therapy (SBRT) 
to the right humeral lesion.
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 services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 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. 
 
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.