Persius/hicric huggingface dataset:
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 stay is medically necessary. 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 the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not show to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen, 
pelvis, and thorax for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there is no result from a 
chest x-ray in the submitted records. Absent these records, medical necessity of the chest CT scan has not been 
established. In terms of the CT of the abdomen and pelvis, there are no lab results from the metabolic panel, 
thyroid-stimulating hormone (TSH), or complete blood count (CBC) are in the records. In addition, the enrollee 
has a body weight of 108 pounds, meaning she likely would be a very good candidate for ultrasound of the 
abdomen and pelvis as a starting point. Absent the above information, the medical necessity of CT of the 
abdomen and pelvis has not been established in the submitted records. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the abdomen, pelvis, and thorax for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the conservative therapy options have not been 
satisfied. 
 
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 Synvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 
69-year-old female with osteoarthritis of the right knee.  She rates her pain 7-10/10.  Her treatment has 
included medical therapy including, topical analgesics. She has declined physical therapy. In this case, the 
enrollee has only been treated with medical therapy. There is no documentation of conservative therapy such as 
physical therapy or previous intra-articular corticosteroids. The review has determined that the documentation 
does not support that Synvisc is medically reasonable or necessary for this patient. The documentation does not 
support that Synvisc is safe and effective for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have 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 Ilumya. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Remicade, Inflectra or infliximab, and Stelara before they will approve the requested drug. In this case, 
the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) would likely be less effective and/or likely have adverse effects for 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
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 able and motivated to participate in 
the 3 hours of individualized rehabilitation with emphasis on strength, gait training, endurance, activity 
tolerance, and activities of daily living in order to return home safely. The Plan denied your request. The Plan 
says authorization denied because IRF is not medically necessary, and the enrollee's needs can be met at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
records do not show that it is medically necessary to be in 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 that the enrollee requires short-term additional acute care hospital services that can 
safely be administered at the current facility until more stable. The enrollee does not require services at the 
LTACH that are not already available at the current 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 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 stay is medically necessary. 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 are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing 
or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service 
criteria for 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder surgery services to be rendered by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve shoulder surgery services. You say that it is medically reasonable and 
necessary. The Plan denied your request. The Plan says there is no medical need for the enrollee to utilize an 
OON provider for the requested services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for 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 shoulder surgery services. Our reviewer 
says that it is not medically reasonable and necessary for the enrollee to receive these services from an OON 
provider. Our physician reviewer found his 66-year-old male was being treated for a history of right shoulder 
replacement; right shoulder pain. He has a surgical history significant for multiple right shoulder surgeries 
including a revision of right total shoulder arthroplasty both glenoid and humeral components with the repair of 
deltoid dehiscence on July 28, 2021. He presented 6 months status post right shoulder revision reverse total 
shoulder arthroplasty and deltoid repair. His right shoulder has continued increased pain and inability to lift his 
arm overhead, due to the pain. He has been wearing the sling to the right upper extremity due to the pain. He 
reports that the deltoid muscle appears to be torn at the front of the shoulder.  
 
However, detailed documentation is not evident regarding any deficits demonstrated on exams or imaging 
studies that support a need for specialized care. The rationale is not evident as to why an in-network provider 
could not perform this procedure. Therefore, it is not medically necessary and reasonable for the enrollee to 
continue to receive shoulder surgery services from an out-of-network provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder surgery services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve shoulder surgery services to be rendered by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
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. The Plan denied your request. The Plan says you do not need an 
intensive program in an acute rehab setting. Your continued care could be provided in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. Although you require physical therapy 
and occupational therapy services, the medical records provided do not clarify why you require an intensive 
inpatient rehabilitation therapy program. Care at the skilled nursing facility level is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick external catheters. 
 
You asked the Plan to pre-approve Purewick external catheters. You say that this is necessary to keep you from 
falling at night. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that female external urinary collection devices are 
covered for beneficiaries who have permanent urinary incontinence when used as an alternative to an 
indwelling catheter.  
 
We looked at the file and Medicare rules. The records do not show that the requested devices are being used as 
an alternative to an indwelling catheter. Based on this information, we decided that Medicare rules for coverage 
of Purewick external catheters have not been met. Therefore, we decided that the Plan does not have to pre-
approve Purewick external catheters.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the head. 
 
You asked the Plan to pre-approve MRI scan of the head. You say that this imaging service is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI scan of the head. Our reviewer 
says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer 
found Telehealth visit on March 7, 2022, described a 69-year-old female with increasing dizziness. Her hearing 
has been reported as normal. MRI of the internal auditory canals (IACs) has been requested but denied due to 
normal neuro exam done by telehealth visit. No detailed physical exam of the cerebellum and brain stem is in 
the records.  Patient reports no tinnitus or hearing loss. MRI of the IAC's in this clinical scenario has not been 
shown to be medically necessary without a neurological or ear, nose and throat consult. The other missing 
piece of clinical info is a Carotid/vertebral duplex scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI scan of the head have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) scan of the head.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast reduction. 
 
You asked the Plan to pre-approve the requested services. You say that have pain in your neck and back. The 
Plan denied your request. The Plan says you have not tried other prescription treatments for your rashes. 
 
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 in this case, the record indicates that you have macromastia. The record does not indicate 
the presence of intertrigo unresponsive to conservative treatments. The record states that endocrine and internal 
medicine consultation have not ruled out endocrine, metabolic or pharmacological causes of macromastia. 
Therefore, 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a breast reduction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary based on Medicare rules. 
 
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 chronic obstructive pulmonary disease (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 the DME. Our physician reviewer 
found a home ventilator is not medically necessary. This patient has severe COPD with a previous 
hospitalization requiring intubation for acute on chronic hypercarbic respiratory failure. This patient has 
apparently had a Trilogy ventilator, at least since that hospitalization. But there is no evidence that bilevel 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) has been tried and 
failed. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the home ventilator (CPT code E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
  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 Euflexxa. Our reviewer says that 
Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Orthovisc 
or Supartz FX. Our reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).