Persius/hicric huggingface dataset:
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that 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. 
 
 
 
 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 home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a setting that could 
be delivered by a BiPAP device is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that you have obstructive sleep apnea untreated, atrial fibrillation, and pulmonary hypertension. You 
were found to be in hypercarbic respiratory failure during a recent hospitalization for heart failure. There is no 
diagnosis of COPD, neuromuscular disease, or thoracic restrictive disease. There is no documentation of 
chronic carbon dioxide retention on an arterial blood gas study done while stable as an outpatient. A BiPAP has 
not been tried at home. You do not have a diagnosis for which Medicare covers a ventilator. Therefore, a home 
ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 admission is medically 
necessary. The Plan denied your request. The Plan says you are receiving appropriate acute care and do not 
require transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with necrotizing fasciitis. The record indicates that you remain 
critically ill with an increasing leukocytosis and you require ongoing acute care services. You continue to 
receive acute care services and these have not been denied.  The medical record does not indicate that you 
require services that you are not currently receiving but that would be available at the LTACH facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (22558). 
 
You asked the Plan to pre-approve the spinal surgery. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested code cannot be approved in an outpatient setting. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the Outpatient 
Prospective Payment System (OPPS) for services that CMS designates to be inpatient-only services. 
 
We looked at the file and Medicare rules. The code requested is an inpatient only procedure being requested in 
an outpatient setting. Based on this information, we decided that Medicare rules for coverage of the spinal 
surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery 
(22558).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics for the enrollee. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve talimogene laherparepvec (J9325). 
 
You asked the Plan to pre-approve talimogene laherparepvec. You say that the enrollee had adverse side effects 
from chemotherapy. You also say that the enrollee is limited to what drugs can be used due to medical history. 
The Plan denied your request. The Plan says the requested drug is considered experimental. The Plan also says 
that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 talimogene laherparepvec. Our 
reviewer says that the requested drug, talimogene laherparepvec, is not medically necessary. Our physician 
reviewer found the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation. The reviewer found there is no literature from 
Medicare approved cancer journals to support the requested drug for the enrollee's clinical situation. Therefore, the reviewer found that the requested drug 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 talimogene laherparepvec have not been met. Therefore, we decided that the 
Plan does not have to pre-approve talimogene laherparepvec (J9325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2203) provided on December 3, 
2021. 
 You asked the Plan to pay for the eyeglasses. You say that you lost your previous eyeglasses and needed a 
replacement. The Plan denied your request. The Plan says you previously received a pair of eyeglasses in 
October 2021, which were covered by the Plan at that time. Your benefit is limited to one pair of lenses and 
frames every 2 years. The eyeglasses purchased on December 3, 2021, exceed the frequency limitation of your 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two years. 
 
We looked at the file and the Plan's rules. Documentation shows that you purchased another pair of eyeglasses 
less than two years before the date in question, and those services were covered by the Plan at that time. Based 
on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2203) provided on 
December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the patient's condition 
does not require position of the body in ways not feasible in an ordinary bed and does not require frequent 
changes in body position. Additionally, the patient's condition does not require special attachments that cannot 
be fixed and used on an ordinary bed. 
 
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 semi electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi electric hospital bed (E0260).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says that evidence-based 
criteria have not been met. 
 
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 Zilretta. Our physician reviewer found 
that the enrollee presents with right knee pain due to unilateral primary osteoarthritis of the right knee. The 
request is for the coverage for an injection of 1mg triamcinolone acetonide preservative-free extended-release 
microsphere formulation (Zilretta). According to the FDA approved prescribing information, Zilretta 
(triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-articular injection for 
the management of osteoarthritis pain of the knee. Extended-release triamcinolone acetonide significantly 
reduced the change in average daily pain intensity scores (ADP) from baseline to week 12 compared with 
placebo in a randomized study of patients with osteoarthritis-associated knee pain. The review indicates that 
the requested use of Zilretta is FDA-approved for the enrollees diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil tablets. 
 
You asked the Plan to pre-approve Tadalafil tablets. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 Tadalafil tablets.  
 
Benefits for Tadalafil 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has difficulty walking. The 
Plan denied your request. The Plan says the device is not indicated for this enrollee. 
 
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 interspinous stabilization devices remain experimental. More research is needed. 
 
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 an interspinous stabilization device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) admission to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON IRF admission. You say that IRF admission is medically necessary. 
The Plan denied your request. The Plan says the requested facility is OON with the Plan, and OON care is not 
covered. The Plan says that they have provided you with in-network facility choices. 
 
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 
inpatient rehabilitation facility (IRF) admission to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide or stair lift. 
 
You asked the Plan to pre-approve a stair glide or stair lift. You say that you and your spouse have serious 
health issues and have great difficulty going up the stairs. You state there are no ranch homes available to rent. 
The Plan denied your request. The Plan says stair lifts are not covered by Medicare under any circumstance. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair 
glide or stair lift.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) (70551), to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that the service should be covered. The Plan denied your 
request. The Plan says there are in-network providers available to perform this service. 
 
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 
the magnetic resonance imaging (MRI) (70551), to be provided by an out-of-network (OON) provider.
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 do not have strength to stand up and get in a 
wheelchair and you need intense rehab to get strength back in your legs. The Plan denied your request. The 
Plan says although you require physical and occupational therapy and pain control, you do not require IRF 
care. You can be managed at a lower level setting. 
 
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 were admitted for back pain. Your medical problems are stable, and you have no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 28, 2021, to November 26, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there 
are no identifiable skilled therapy service needs. There are no identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 28, 2021, to 
November 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto tablets for the enrollee. 
 
You asked the Plan to pre-approve Xarelto tablets. You say that Xarelto tablets are medically necessary. The 
Plan denied your request. The Plan says Xarelto tablets are 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 Xarelto tablets for the 
enrollee.  
 
 Benefits for Xarelto 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that a raised toilet seat is medically necessary. 
The Plan denied your request. The Plan says a raised toilet seat is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.