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 an IRF admission is recommended to medically and 
functionally assess the member to determine if they will benefit from this level of care. The Plan denied your 
request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic radiation therapy (SBRT). 
 
You asked the Plan to pre-approve stereotactic radiation therapy (SBRT). You say that the requested 
stereotactic radiation therapy (SBRT) is medically necessary. The Plan denied your request. The Plan says the 
requested stereotactic radiation therapy (SBRT) 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 stereotactic radiation therapy (SBRT). 
Our reviewer says that the requested stereotactic radiation therapy (SBRT) is not medically necessary. Our 
physician reviewer found SBRT, delivering high fractional doses in 3-5 fractions is an established approach for 
the treatment of discrete lesions from cancer. For metastatic disease, SBRT is generally indicated for patients 
with oligometastatic disease or for those undergoing palliation after prior radiation to the same site. Neither of these apply to this enrollee. Oligometastases are defined as a state of metastatic disease with metastases few in 
number and extent. 
 
The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting 
national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically 
necessary when the patients performance status justifies aggressive treatment, and for those whose tumor 
burden can be completely targeted with acceptable risks (which does not apply in the setting of 
oligoprogression- i.e. one or few lesions growing in setting of widespread progression). Per ASTRO model 
policy, SBRT is only necessary if it can be safely delivered when encompassing all sites of disease, which 
would not apply for this enrollee to undergo radiation for palliative intent to one site in the setting of 
widespread disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stereotactic radiation therapy (SBRT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stereotactic radiation therapy (SBRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azacitidine and Ondansetron. 
 
You asked the Plan to pre-approve Azacitidine and Ondansetron. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee is enrolled in a clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Azacitidine and Ondansetron as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve Azacitidine and Ondansetron.
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 cannot be safely discharged, they still 
need assistance. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are medically necessary. The Plan denied your request. The Plan says the requested item is not 
covered. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction of tooth 14 and tooth 31 (D7210), 
deep sedation/general anesthesia (D9222), deep sedation/general anesthesia-each subsequent 15-minute 
increment (D9223), therapeutic parenteral drugs (D9612), and primary closure of sinus perforation (D7261). 
 
You asked the Plan to pre-approve dental codes D7210, D9222, D9223, D9612, and D7261. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental codes D7210, 
D9222, D9223, D9612, and D7261 are not covered by Medicare or the Plan for your condition. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental codes D7210, D9222, D9223, 
D9612, and D7261 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical extraction of tooth 14 and tooth 31 (D7210), deep sedation/general anesthesia 
(D9222), deep sedation/general anesthesia-each subsequent 15-minute increment (D9223), therapeutic 
parenteral drugs (D9612), and primary closure of sinus perforation (D7261).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to a lower limb prosthesis, multiaxial ankle 
(L5968) and a flex-walk system for a lower limb prosthesis (L5981). 
 
You asked the Plan to pre-approve a lower limb prosthesis addition and flex-walk system. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the documentation 
does not show why these parts for the prosthesis are needed. 
 
The Plan follows Medicare rules. Medicare rules say that a flex foot system is covered for enrollee's whole 
functional level is K3 or above. 
 
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 lower limb prosthesis addition and 
flex-walk system. Our reviewer says that the coverage criteria has not been met. Our physician reviewer found 
that the documentation does not support that the enrollees activities cannot be met with the current foot. 
Additionally, the documentation indicates that the enrollee is expected to not need an assistive device within 
the next three months. The enrollee is on opioids for pain management. The documentation does not support 
that the enrollee is a K3 ambulator and that their needs cannot be met with a lower level foot. 
 
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 lower limb prosthesis addition and flex-walk system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an addition to a lower limb prosthesis, 
multiaxial ankle (L5968) and a flex-walk system for a lower limb prosthesis (L5981).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has iron deficiency anemia. The requested medication is a new start. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior cervical spine fusion from C4-C7 using the 
Providence DTRAX cervical posterior fusion instrumentation system. 
 
You asked the Plan to pre-approve posterior cervical spine fusion from C4-C7 using the Providence DTRAX 
cervical posterior fusion instrumentation system. You say that the requested posterior cervical spine fusion 
from C4-C7 using the Providence DTRAX cervical posterior fusion instrumentation system is medically 
necessary. The Plan denied your request. The Plan says the requested posterior cervical spine fusion from C4-
C7 using the Providence DTRAX cervical posterior fusion instrumentation system 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 posterior cervical spine fusion from C4-
C7 using the Providence DTRAX cervical posterior fusion instrumentation system. Our reviewer says that the requested posterior cervical spine fusion from C4-C7 using the Providence DTRAX cervical posterior fusion 
instrumentation system is not medically necessary. Our physician reviewer found the DTRAX posterior facet 
fusion device is experimental. More research is needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of posterior cervical spine fusion from C4-C7 using the Providence DTRAX 
cervical posterior fusion instrumentation system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve posterior cervical spine fusion from C4-C7 using the Providence DTRAX cervical 
posterior fusion instrumentation system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission. The Plan denied your request. The Plan says criteria for admission to the IRF 
setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not safe for discharge and will not 
receive the care needed in a skilled nursing facility. The Plan denied your request. The Plan says the services 
the enrollee needs can be provided safely in another setting such as a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel. 
 
You asked the Plan to pre-approve a targeted genomic sequence analysis panel. 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 Next Generation Sequencing (NGS) is covered under 
certain circumstances. 
 
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 targeted genomic sequence analysis 
panel. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
requested test is not reasonable and necessary because Tempus xF has not had FDA approval or clearance as a 
companion in vitro diagnostic or an FDA-approved or -cleared indication for use in this enrollee's cancer. The 
review has determined that the enrollee does not meet the coverage criteria detailed in the NCD. 
 
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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel.
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 assistance due to lack of mobility. The Plan 
denied your request. The Plan says you do not require 3 hours of therapy a day. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for lumbar spine surgery. Your medical problems are stable. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation 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 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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate in-patient care and 
is currently unstable for a transfer to an 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 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. The health 
plan has approved ongoing care in the current acute care 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 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 office visits (99202, 99203, 99204, 99205) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that the enrollee needs expert assistance in treatment. 
She has developed nodules in her abdomen causing her constant and severe pain. The Plan denied your request. 
The Plan says the enrollee must use network providers to receive care/services. 
 
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 
office visits (99202, 99203, 99204, 99205) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.