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 the member's current medical condition requires an 
IRF admission. The Plan denied your request. The Plan says the member does not meet the criteria for an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the requested scooter is medically 
necessary. The Plan denied your request. The Plan says that a power scooter is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that you can accomplish most of your 
daily activities independently and you have help for those which require assistance. It is noted that you have 
full motor strength in most of your upper and lower extremity muscle groups and have good sitting and 
standing balance. There is no reason that you cannot propel a manual wheelchair if it is needed. The 
occupational therapy assessment also indicates that your currently living situation is not amenable for a power 
scooter. 
 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (MyoPro Orthosis) (L8702). 
 
You asked the Plan to pre-approve MyoPro Orthosis. You say that the requested item is medically necessary 
for the enrollee. 
 The Plan denied your request. The Plan says the requested item 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 MyoPro Orthosis. Our reviewer says 
that the requested MyoPro Orthosis is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for the enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. Therefore, the reviewer found that the requested item 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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (MyoPro Orthosis) (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One (J7326). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 the medication. Our physician reviewer 
found you have not trialed one of the preferred viscosupplemental treatments such as, Durolane, Euflexxa, Supartz FX, or GelSyn-3 before they will approve the requested drug. Step therapy, as outlined by the Plan, 
requires that one of these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the Plans additional required drug would likely be less effective 
and/or likely have adverse effects for you. Without the support of the documentation, Gel-One is not approved 
as step criteria has not 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel One (J7326).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a comprehensive electrophysiologic evaluation and catheter 
ablation of atrial fibrillation. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation indicating medications have been tried/failed in the past 
from various tiers to indicate a repeat ablation procedure is warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 study. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient had an unsuccessful ablation attempt in 2020 at a distant medical center which was 
unsuccessful and with a vascular complication. Recent randomized clinical studies have supported the role of 
catheter ablation for the treatment of symptomatic atrial fibrillation as an acceptable first-line alternative to 
medications in the treatment of patients with this arrhythmia. The clinical guidelines have been modified to 
reflect the findings of these new studies. Therefore, electrophysiologic evaluation and catheter ablation of atrial 
fibrillation would be considered medically appropriate in this patients clinical management. 
 
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 study have been met. Therefore, we decided that the Plan has to pre-approve 
a comprehensive electrophysiologic evaluation and catheter ablation of atrial fibrillation.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for the purpose of travel. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that a 
portable oxygen concentrator is considered not medically necessary because Medicare criteria are not met.  The 
patient is on home oxygen at night, with continuous positive airway pressure (CPAP), and during exertion. The 
patient is requesting the portable oxygen concentrator for purposes of air travel. This is not covered by 
Medicare. In addition, there is no testing to document that the patient can maintain an oxygen saturation greater 
than 91% during exertion with oxygen at 1 to 4 L/min using an oxygen conserving device. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve repeat bilateral knee injections of Zilretta. 
 
You asked the Plan to pre-approve the Zilretta injections. You say that this has been the only treatment that 
helped with the enrollee's pain. It should be allowed. The Plan denied your request. The Plan says that this drug 
is not approved for repeat use after the first treatment. 
 
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 the Zilretta injections. Our reviewer 
says that the documentation and literature support that the requested use of Zilretta is medically reasonable and 
necessary. Our physician reviewer found the enrollee is a female with bilateral knee pain due to osteoarthritis. 
She has been treated with medication, viscosupplementation therapy, and Zilretta injections. Zilretta 
(triamcinolone acetonide extended-release injectable suspension) is indicated as an intra-articular injection for 
the management of osteoarthritis pain of the knee. The product label indicates a limitation of use stating that 
"the efficacy and safety of repeat administration of Zilretta have not been demonstrated." However, it does not 
preclude use of the drug more than one time. The documentation supports that Zilretta is medically reasonable 
and necessary 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 the Zilretta injections have not been met. Therefore, we decided that the Plan 
has to pre-approve repeat bilateral knee injections of Zilretta.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary for malignant 
neoplasm of the prostate. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that proton beam radiation therapy (PBRT) is not medically reasonable and necessary in this case. There 
is insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation 
therapy for prostate cancer is superior, inferior, or equivalent to external beam radiation therapy, intensity-
modulated radiation therapy, or brachytherapy with regards to safety and efficacy. Recent data shows no 
significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton 
beam therapy and intensity-modulated radiation therapy. 
 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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services to be provided by an OON provider. 
 
You asked the Plan to pre-approve SNF services. You say that the recommended facility is not healthy or safe. 
The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 
SNF services to be provided by an OON provider.
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 member's current medical condition 
requires an LTACH level of care. The Plan denied your request. The Plan says there is no documentation that 
the enrollee will benefit from and improve with LTACH management. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee is 
receiving appropriate care at the present acute care hospital. 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. 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 SPRINT PNS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this device is considered experimental/investigational for knee pain. Therefore, 
the request is not medically reasonable and 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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT peripheral nerve stimulator (PNS) system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zirabev (Q5118), Ondasetron (J2405), famotidine 
(J3490) and dexamethasone (J1100). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says based on review of the National Comprehensive Cancer Network 
(NCCN) and all other pertinent compendia, support is not found for this usage. 
 
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 medication. Our physician reviewer 
found the requested use of Zirabev (Q5118) is not FDA-approved for the enrollee's diagnosis. Zirabev is not 
FDA-approved as second-line treatment of adenocarcinoma of the lung. The use is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix 
for list of Centers for Medicare & Medicaid Services (CMS)-approved journals). 
 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zirabev (Q5118), Ondasetron (J2405), famotidine (J3490) and dexamethasone (J1100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183). You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that you disagree with the 
denial and are requesting reconsideration. The Plan denied your request. The Plan says the request is not 
medically necessary because records show the enrollee does not have measure signs of healing during the 
treatment period with HBO dating January 3, 2023, through March 3, 2023. The enrollee does not meet the 
requirements for approval. 
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided, there is no documentation that 
the additional hyperbaric oxygen treatment at issue in this case meets the NCD criteria for medically 
reasonable and necessary for the enrollee. Provided records in this case do not document improvement in the 
wound with the hyperbaric oxygen treatment provided thus far as required by the NCD. As of January 16, 
2023, just before the hyperbaric oxygen treatment started, the wound was 7.5 cm x 4 cm x 0.2 cm with an area 
of 23.562 square cm and a volume of 4.712 cubic cm. As of March 13, 2023, the wound was 9.5 cm x 6.3 cm x 
0.9 cm with an area of 47.006 square cm and a volume of 42.305 cubic cm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277) and physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).