Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from June 20, 
2022 onward. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with a severe recurrent major depressive episode with catatonia. Based on the submitted records, it is 
not expected he will improve in a reasonable period of time beyond the dates in question, as he is not showing 
dangerousness to self or others and has no auditory or visual hallucinations or abnormal behaviors. He is 
compliant with care. It does not appear that active treatment is taking place beyond the dates in question. The 
services are not reasonably expected or medically necessary to improve his condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from June 20, 2022 onward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve INJECTAFER (J1439). 
 
You asked the Plan to pre-approve INJECTAFER. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the member did not meet step therapy requirements for this drug. 
 
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 member does not meet step therapy requirements for this drug. Our physician reviewer found 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 INJECTAFER have not been met. Therefore, we decided that the Plan does not 
have to pre-approve INJECTAFER (J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair (PWC) with power tilt and recline. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
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 medically necessary. Our physician reviewer found you have a history of cerebrovascular 
accident (CVA), chronic obstructive pulmonary disease (COPD), and neuropathy with mobility impairments. 
The clinical documentation justifies a Group 3 PWC frame and tilt with risk for pressure ulcers and recline is 
justified by need for positioning. The requested PWC is reasonable and medically necessary for you and meets 
the Medicare coverage criteria. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a Group 3 power wheelchair (PWC) with power tilt and recline.  
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-home support services. 
 
You asked the Plan to pre-approve the in-home support services.. You say that the service is medically 
necessary. The Plan denied your request. The Plan says you are not being discharged from a hospital or skilled 
nursing facility. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the in-home support services. have not been met. Specifically, you are not being discharged from a 
hospital or skilled nursing facility, but relocating from residential home care. This means you do not qualify for 
this supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve the in-home 
support services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not require frequent self-adjustment of insulin dosage 
based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and 
supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve repeat ESI services. You say that this injection is medically necessary for 
your pain management. The Plan denied your request. The Plan says the criteria for repeat ESI services have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI services when the first injection 
directly and significantly provided improvement of the condition being treated may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline for at least three months. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support that the initial 
injection was over 3 months ago. Based on this information, we decided that Medicare rules for coverage of 
repeat ESI services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat 
epidural steroid injection (ESI) 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the records do not show that is it medically necessary to 
be in an LTACH in place of an acute care hospital. 
 
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 at the LTACH that the patient requires that are not already 
available and covered at the current facility, and a transfer to LTACH is not medically necessary as the patient 
is unstable and as it would not be clinically advantageous. Our doctor also found that completion of treatment 
at the current facility is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ARANESP (J0881). 
 
You asked the Plan to pre-approve ARANESP. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the member does not meet step therapy requirements for this drug. 
 
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 ARANESP. Our reviewer says that the 
member does not meet criteria for this drug. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative and 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 ARANESP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ARANESP (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ramp for a scooter. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ramp for a scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic low back pain and 
lumbar spinal stenosis (narrowing of the spine). The records show you have multi-level degenerative changes 
ranging from mild to severe. The records do not show that you cannot have surgery at no more than two levels. 
The records do not support that the Vertiflex Superion spacer is reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis surgery with allograft. 
 
You asked the Plan to pre-approve spine surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
records do not show that previous cervical fusion failed or consideration of alternative treatments. 
 
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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the diagnostic imaging study provided did not demonstrate and pseudoarthritis of the cervical 
spine. Additionally, there are no recent objective examination findings of the cervical spine to corroborate any 
deficits or severe/progressive neurological abnormalities. Detailed documentation is not evident regarding trial 
and failure of recent, reasonable, and comprehensive less-invasive conservative care measures. There is no 
compelling rationale or extenuating circumstance noted to support the medical necessity of this request as an 
exception to guidelines. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis surgery with allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services (99204) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that this care is necessary for your medical 
treatment. The Plan denied your request. The Plan says there are other in-network options available to choose 
from for medical care. 
 
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 visit services (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for contact lens, scleral, gas permeable 
(V2531), and fitting of contact lens (92072). 
 
You asked the Plan to pay an additional amount for contact lens, scleral, gas permeable, and fitting of contact 
lens. You say that the lenses are for an irregular astigmatism. The Plan denied your request. The Plan says the 
enrollee is responsible for all costs above the $600 maximum plan coverage benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of contact lens, scleral, gas permeable, and fitting of contact lens have not been met. Specifically, the 
Plan offers up to $600 for coverage for lenses. The enrollee is responsible for all costs above the $600 
maximum benefit. Therefore, we decided that the Plan does not have to pay an additional amount for contact 
lens, scleral, gas permeable (V2531), and fitting of contact lens (92072).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with a tertiary level of care provider. 
 
You asked the Plan to pre-approve outpatient treatment. You say that you are afraid that you will not be able to 
get the treatment needed to extend life. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because tertiary level of care is not medically necessary and you can be treated by a 
non-tertiary (community-level) provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
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 outpatient treatment. Our reviewer says 
that you do not meet the Medicare criteria for treatment at the tertiary level of care. Our physician reviewer 
found the Plan is offering adequate care to meet your medical needs through referral to a non-tertiary level of 
care provider. There is nothing unique noted in the documentation about your condition that would make it 
medically necessary for you to see the requested tertiary level of care provider. The Plan has non-tertiary 
(community-level) providers who meet the standards of care to treat 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 outpatient treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve office visits with a tertiary level of care provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Retacrit or Procrit before it will approve Aranesp. 
 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 Aranesp. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Aranesp. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Retacrit or Procrit. The record does not 
show that these drugs would likely be less effective and/or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Aranesp.