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

 
We decided that the Plan does not have to pre-approve Krystexxa. 
 
You asked the Plan to pre-approve Krystexxa. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Krystexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of severe chronic gout.  The record indicates that the 
enrollee has a uric acid level of 1.9. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage 
criteria are not satisfied. The requested drug cannot be considered for a step therapy exception because 
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 Krystexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Krystexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit services provided on September 14, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visit services. You say that you would like reconsideration because 
these services were not rendered. The Plan denied your request. The Plan says these services were not urgent, 
emergent or approved in advance. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit 
services provided on September 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 01740 provided on August 25, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says the services have already been 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 01740 is not supported in the medical record. Specifically, this claim is an exact 
duplicate to services already been paid. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01740 provided on 
August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy. 
 
You asked the Plan to pre-approve the diagnostic colonoscopy. The Plan denied your request. The Plan says the 
request for a diagnostic colonoscopy is not medically necessary. 
 
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 diagnostic colonoscopy. Our 
reviewer says that there is no documentation that you meet the Medicare criteria for coverage for a diagnostic 
colonoscopy. Our physician reviewer found the records document the colonoscopy was ordered for screening. 
Our reviewer found that the records do not document any active symptoms, findings or conditions required by 
the Local Coverage Determination (LCD) for coverage for a diagnostic colonoscopy. Our physician reviewer 
also found that a screening colonoscopy appears to be indicated 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 the diagnostic colonoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a diagnostic colonoscopy.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to go home right now. You say that 
you are not strong enough to return home, as you live alone and are very weak. The Plan denied your request. 
The Plan says that the guidelines for coverage of SNF care have not been met. The Plan says that the services 
required can safely be received at a different setting. 
 
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 the 
criteria for coverage have been met. Our physician reviewer found there is documentation that the patient 
requires skilled nursing services. The records document placement of a new G-J feeding tube on March 9, 
2022, which is a daily skilled nursing need. The medical records provided show that the enrollee does require 
skilled therapy services. While there is no documentation showing that the skilled therapy services are required 
daily, the skilled nursing services related to the new tube feeding are required on a daily basis. There is 
documentation that the enrollee requires the services on an inpatient basis in a skilled nursing facility setting 
related to the new daily skilled nursing needs related to the G-J feeding tube.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options.  
You asked the Plan to pre-approve group 3 power wheelchair with multiple power options. You say that the 
power options are needed to allow the enrollee to independently perform pressure relief and positioning. The 
Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee does not require the multiple requested power options and a different power mobility device may be 
considered instead. 
 
The Plan follows Medicare rules. Medicare rules state that a group 3 power wheelchair with multiple power 
options may be covered if certain criteria are met. 
 
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 group 3 power wheelchair with multiple 
power options. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested group 
3 power wheelchair. Our physician reviewer found the enrollee does have a group 3 qualifying diagnosis of a 
neurological condition from a traumatic brain injury. However, the documentation does not support that the 
enrollee is at high risk for development of a pressure ulcer or utilizes intermitted catheterization for bladder 
management. The physician documentation does not indicate evidence of spasticity that needs a power seating 
system for management; therefore, the requested power tilt/recline exceeds the enrollee's medical needs and a 
group 3 power wheelchair with multiple power options is 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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zilretta hip injection. 
 
You asked the Plan to pre-approve the Zilretta hip injection. You say that this should be approved to help treat 
the enrollee's hip pain. The Plan denied your request. The Plan says this is not indicated for use in the hip. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Zilretta hip injection. Our reviewer 
says that the requested use of this drug is not medically reasonable and necessary. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of arthritic hip pain. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied.  
 
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 Zilretta hip injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Zilretta hip injection.
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 Plan denied your request. The 
Plan says the enrollee does not require daily physician visits. 
 
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  Our physician reviewer found that the enrollee has esophageal cancer. 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 enrollee 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires interdisciplinary therapy care. 
The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other 
settings. 
 
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 enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. He needs to be medically stable. At the current functional level with no prosthesis, the 
enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach to daily therapy in an IRF. The enrollees rehab needs can be met at a 
lower intensity setting. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
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 for the enrollee.
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 was admitted to a SNF, and a discharge 
was placed, and they were transferred to a board and care facility. You state you feel that the enrollee still 
needs daily occupational and physical therapy as they have recently fallen twice since being discharged from 
the facility. You state that you would like the enrollee to be readmitted to the SNF due to their current health 
conditions and feel they needs the skilled services. The Plan denied your request. The Plan says the stay is not 
medically necessary based on SNF 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex 
wound care. This enrollee does not require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist are not required to safely and effectively provide medically necessary and 
reasonable treatment. There is no documentation that daily skilled services are required. The enrollee appears 
to have plateaued with the therapy they have recently received, and records report he has reached "maximum 
potential." There is no documentation that the enrollee requires the services on an inpatient basis, only in a SNF 
setting. Services in the "board and care" facility 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter for the enrollee. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says a scooter for use in the community is not covered. 
 
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 the scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the enrollee has a 
mobility limitatio,n but the documentation is not clear that it impairs MRADLs in the home as the 11/15/21 
document indicates the enrollee is independent in dressing, bathing, feeding grooming. The documentation on 
9/8/21 indicates the enrollee wants a scooter for outside the home. The 11/15/21 and the 9/8/21 document 
indicate the enrollee has visual impairment and was to go for follow up.  The documentation is not clear that the enrollee has had an eye examination supporting that he is safe to use a 
mobility device. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that the requested Granix is medically necessary. The Plan 
denied your request. The Plan says the requested Granix is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Granix. Our reviewer says that the 
requested Granix is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of leukopenia attributed to Valcyte.  The record indicates that the enrollee does not 
have a non-myeloid malignancy. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition.  The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.