Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management (EM) services provided on September 
15, 2021. 
 
You asked the Plan to pay for the EM services. You say that the provider is both a chiropractor and a nurse 
practitioner. As such, EM services should be payable. The Plan denied your request. The Plan says that EM 
services cannot be paid to a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide a valid denial rationale. It is noted that this was 
denied due to the provider being a chiropractor, and only manual spinal manipulation is covered from this type 
of provider. While this is correct, the appellant submitted clear evidence showing this provider is also a nurse 
practitioner. Nurse practitioners may be paid for EM services. The claim also indicates that this visit was 
rendered due to suspected COVID-19 exposure, and not for chiropractic care. Based on this information, we 
find that the denial of payment in this case is not substantiated. Therefore, we decided that the Plan has to pay 
for the evaluation and management (EM) services provided on September 15, 2021.  
 
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 Vertiflex Superion device. 
 
You asked the Plan to pre-approve Vertiflex Superion device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is unproven, experimental and has insufficient evidence 
of efficacy. 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization services. 
 
You asked the Plan to pre-approve the revascularization services. You say that you would like reconsideration 
because this intervention is medically necessary. The Plan denied your request. The Plan says records do not 
show that the enrollee has iliac artery stenosis or clinical symptoms consistent with blockage in the iliac artery. 
 
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 revascularization services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provider performed an iliac artery intervention for an incidentally noted 
79.6% stenosis of the iliac artery. The record provided form prior to the intervention does not indicate that the 
enrollee had any symptoms or the reason for the intervention. 
 
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 revascularization services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve revascularization services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temazepam. 
 
You asked the Plan to pre-approve Temazepam. You say that the enrollee cannot take generic due to his age, 
and you would like the request for Temazepam to be reconsidered. The Plan denied your request. The Plan says 
Temazepam is a self-administered drug and does not fall under Part B coverage. 
 
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 Temazepam.  
 
 
 Benefits for Temazepam 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the documentation does 
not show that the enrollee has had a therapeutic failure on, intolerance to, or contraindication to Avastin. 
 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 Eylea. Our reviewer says that Eylea is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided records do 
not indicate that the enrollee has failed the plan's preferred step one alternative. Our reviewer found that the 
record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from 
continuing with the plan's preferred step one alternative. Our physician reviewer also found that 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan (J8499). 
 
You asked the Plan to pre-approve Xifaxan. You say that the enrollee has been diagnosed with Hepatic 
encephalopathy. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition by their Medicare Part B 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 Xifaxan (J8499).  
 Benefits for Xifaxan 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: 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 you have received two hip fractures and you are 
losing the ability to move freely and are in need of therapy. The Plan denied your request. The Plan says SNF 
care is not medically necessary and you can be managed at a lower level of care. 
 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 you do not have documented skilled nursing 
needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of your 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve 9 additional home health skilled nursing visits. You say that you need 
continued home health services to ensure that you are taking your medication in time and the correct dosage. 
The Plan denied your request. The Plan says 9 additional home health skilled nursing visits are not medically 
necessary. Your condition is stable with no recent change to the treatment plan or medications 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 9 additional home health skilled nursing 
visits. Our reviewer says that 9 additional home health skilled nursing visits are not medically necessary. Our 
physician reviewer found you do not have documented skilled nursing needs (i.e. IVs, complex wound care, 
new ostomy, etc.). As such, the requested home health skilled nursing services are 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 9 additional home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 9 additional home health skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that without Rituxan, the cancer will come back. The Plan 
denied your request. The Plan says the length of maintenance therapy has exceeded two years. 
 
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 Rituxan. Our physician reviewer found 
that the enrollee has a medical history of low-grade B-cell non-Hodgkin's lymphoma with no evidence of active 
recurrence. Continued maintenance treatment with Rituxan beyond two years has been requested. There is no 
documentation that Rituxan for maintenance treatment of low grade B-cell non-Hodgkin's lymphoma beyond 
two years is FDA-approved. The requested use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and 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 Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no 
longer require daily skilled services. 
 
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. Continued SNF services beyond April 18, 2022, were 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 pre-approve continued services. Our physician reviewer found that you are ambulating 100 feet 
using a four-wheeled walker with contact guard assist. There are no identifiable skilled nursing service needs. 
Although you do require skilled therapy services, the documentation does not support skilled services on a 
daily 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Orthosis. 
 
You asked the Plan to pre-approve the MyoPro Orthosis. You say that you would like reconsideration because 
the requested equipment is medically necessary. The Plan denied your request. The Plan says the MyoPro 
Orthosis is not known to be effective, based on scientific evidence, professional standards, and expert opinion, 
in improving health outcomes. 
 
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 MyoPro Orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro Orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that your health is in danger, and you need to have a 
continuous stay at the skilled nursing facility. You say that you need more time so you can function at home by 
yourself. The Plan denied your request. The Plan says you no longer require daily skilled services and the 
continuation of SNF 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 services. Our reviewer says that 
daily skilled nursing services are not required. Our physician reviewer found that although you require skilled 
therapy services, they are not required on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of inpatient psychiatric services. 
 
You asked the Plan to pre-approve a continuation of inpatient psychiatric services. You say that you are still 
being monitored for medication compliance and discharge planning is still incomplete. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee has no 
medical problems that require hospital care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient psychiatric 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on April 8, 2022, with Schizophrenia 
Spectrum Disorder. It was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations 
and was without aggressive behaviors while not showing any acute threats of safety. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollees condition or for the 
purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of April 15, 2022, forward 
and could have been treated in a lesser restrictive 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 a continuation of inpatient psychiatric services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation of inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve the Aranesp. You say that you would like reconsideration because the 
requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not being 
prescribed for medically accepted indication. 
 
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 the Aranesp. Our reviewer says that the 
enrollee has a diagnosis of  chronic anemia related to multifactorial causes including: ulcerative colitis, chronic 
inflammation, and iron and  B12 deficiency.  The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. Our physician reviewer found the Medicare approved  
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation.  The elements of the coverage criteria are not satisfied. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Aranesp have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
records do not show failure of more conservative attempts to manage pain. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are 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 are being treated for radiculopathy, the lumbar region. You presented with continued 
pain in the lumbar spine, with only 50% improvement with the right L4-L5 and L5-S1 facet injection. The 
exam reveals a limp and antalgic gait. There are diminished knee and ankle reflexes bilaterally. Pain is elicited 
by motion. Strength is decreased at 4/5 in the bilateral upper extremity in abduction deltoid, flexion biceps, 
extension triceps, flexion wrist, flexion fingers, and abduction fingers. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures including any recent physical therapy. Moreover, 
there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the requested stimulator is not being offered as a last option and 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.