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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting 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 document does not support the medical necessity for admission to an IRF. While the enrollee may benefit from continued PT and OT, the enrollee's rehab needs can be safely provided in 
a lower intensity and alternate setting such as in-home with 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy to recover from your 
injuries. You say that you are unable to walk and there is no one at home to assist you. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 you were admitted for rib fractures and surgical repair of a tibial fracture after a 
fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need 
for physical 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says you have not tried 
and failed Synvisc, Durolane, and Gelsyn-3 
 
 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 physician reviewer found 
that you have bilateral primary osteoarthritis of the knees. The Plan requires a trial of Synvisc, Durolane, and 
Gelsyn-3 before they will approve the requested drug. In this case, you have not tried and failed the required 
drugs. There is no documentation indicating that the Plans required drugs would likely be less effective or 
likely have adverse effects. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LTACH services. 
 
You asked the Plan to pay for the LTACH services. You say that you they believe the enrollee needs LTACH 
services and the enrollee does not need to stay in an intensive care unit and the enrollees care needs are too 
complex for a skilled nursing facility. The Plan denied your request. The Plan says the records do not show that 
the enrollee needs continued treatments that can only be given in a hospital setting. When the enrollee is ready 
to leave the hospital, the enrollee can safely receive this care in another setting, such as a skilled nursing 
facility or at home with home health services or outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 does not require services at the LTACH that are not available at the acute care 
hospital where he/she is currently receiving care. All medically necessary care is being provided in the current 
acute care setting.  
 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 health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 pay for the LTACH services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve the requested services. You say that you are in too much discomfort to 
sleep. The Plan denied your request. The Plan says that you do not meet the requirements. 
 
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation is only covered under 
certain medical indications.  
 
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 you have benign prostatic hyperplasia and lower urinary tract symptoms. You have been on 
Finasteride and Alfuzosin but developed urinary retention and has failed a trial of voiding. IPSS was 35 prior to 
retention. Prostate volume is 127.7 by TRUSP. Cystoscopy shows trilobar obstructive BPH. The records show 
that the coverage criteria have been met. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve a transurethral waterjet ablation of the prostate.  
 
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: 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 are requesting an expedited reconsideration of 
the denied authorization for inpatient rehabilitation facility admission. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare guidelines as they are receiving adequate and necessary physician 
supervision and rehabilitation in the long term acute care facility. 
 
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 was admitted for coronary artery bypass grafting, sternal wound 
infection, and lung infection. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. While the enrollee has a need for physical 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioness functional electrical stimulator (FES). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that FES is covered for spinal cord injury (SCI) patients 
that meet specific criteria. 
 
We looked at the file and Medicare rules. The file shows that you do not have a spinal cord injury. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Bioness functional electrical stimulator (FES).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy for the 
enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available from a provider in-network. 
 
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 
an out-of-network referral for physical therapy for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the additional trips 
are medically necessary. The Plan denied your request. The Plan says the transportation benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services. 
 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says there is no 
documentation of medical complications associated with the approved procedures. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
The file shows that an inpatient hospital admission for approved shoulder arthroplasty was requested. 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 inpatient hospital care. Our physician reviewer found that 
the enrollee has left shoulder joint osteoarthritis and plans for an elective nonemergent left reverse total 
shoulder arthroplasty. The enrollee has a history of hypertension, asthma, and kidney stones.  However, the provided records did not clearly describe the patient as being at a high risk or unstable to suggest 
a need for hospital services that would be expected to cross 2 midnights related to this planned procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer cardiac device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
not proof that the device is safe and helpful for the enrollee's condition. 
 
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 the enrollee has left ventricular dysfunction and continued symptoms, despite medical 
treatment, thought to reflect congestive heart failure. The implantation of a cardiac contractility modulation 
system in the form of the Optimizer Smart device (CCM) has been requested. While the clinical studies led to 
FDA approval in 2019, the CCM remains the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system is not considered medically necessary for this 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Optimizer cardiac device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Zip procedure (22612, 22840). 
 
You asked the Plan to pre-approve an Aurora Zip procedure. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage have not 
been met because the requested service is experimental/investigational. 
 
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 an Aurora Zip procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested device is still considered experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Aurora Zip procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Aurora Zip procedure (22612, 22840).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denied service 
with medical records. The Plan denied your request. The Plan says all services that the enrollee needs are being 
provided in the current acute care setting which is already approved. When the enrollee is medically stable and 
no longer requires an acute level of care the enrollee's ongoing needs may be completed in a lower level of care 
such as an inpatient rehabilitation facility or even a skilled nursing facility. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  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 health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) of the head provided on March 15, 2022. 
 
You asked the Plan to waive the copayment for the CTA. You say that you were not aware of the copayment. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for advanced imaging services, including CT scans, provided in an outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for the CTA. The CTA falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a computed tomographic angiography (CTA) of the head provided on March 15, 2022.