Persius/hicric huggingface dataset:
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 the enrollee requires LTACH level of 
care in order to recover and get back to the previous lifestyle. The Plan denied your request. The Plan says he 
records do not show that it is 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 the enrollee was admitted with acute on chronic respiratory failure secondary to 
pneumonia in the setting of chronic rejection of a lung transplant. The record does not indicate that the enrollee 
remains critically ill and requires acute critical care services before transitioning to a lower level of care. The 
enrollee continues to receive acute care services and these have not been denied. The medical record does not 
indicate that the enrollee requires services not currently receiving but that would be available at the LTACH 
facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 denial of long-term 
acute care hospital admission. The Plan denied your request. The Plan says the service requested is not 
supported based on the records we received. 
 
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 you have a history of hypertension, and hemorrhage/ischemic cerebrovascular 
accident who was admitted from home on July 26, 2022. A computerized tomography in the emergency 
department revealed an acute parenchymal hemorrhage in the left basil ganglia and internal capsule. You 
required intubation and respiratory failure and was extubated. You also required treatment for pneumonia and 
are now stable. There is no documentation provided indicating medical necessity for admission to a LTACH. 
You are receiving the appropriate care at the present acute care hospital. You do not require services at the 
LTACH that are not available at the acute care hospital where you are receiving care. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve conduction test provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for a nerve conduction test. You say that you should not be 
responsible for this cost share. The Plan denied your request. The Plan says the cost share was applied 
correctly. 
 
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 $0 
copayment or a $75 copayment for Medicare-covered diagnostic procedures and tests: a $0 copayment for 
EKG and diagnostic colorectal screenings or a $75 copayment for all other diagnostic procedures and tests.  
You have been asked to pay $75 for a nerve conduction test. A nerve conduction test 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 nerve conduction test provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator. 
 
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 a bone growth stimulator 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 not medically necessary. Our physician reviewer found the records show that you have a closed 
fracture on the left foot diagnosed as a Jone's fracture. There is no imaging evidence of a non-union fracture 
and there are not two sets of x-rays separated by a minimum of 90 days. The criteria for coverage are not met 
and the services are therefore 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 an ultrasonic bone growth stimulator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the use of this drug is not medically accepted for the enrollee's condition. 
 
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 Reblozyl. Our reviewer says that the 
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the enrollee has been diagnosed with primary myelofibrosis positive for Janus Kinase 2 gene mutation. 
In this case, the requested use of Reblozyl is not FDA-approved for the enrollees diagnosis. However, the use 
of Reblozyl is supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Specifically, the use of Reblozyl for the enrollee's condition is supported in the 
National Comprehensive Cancer Network Guidelines Version 3.2022: Myeloproliferative Neoplasms. The 
requested drug satisfies the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve 
Reblozyl.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under Medicare guidelines. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for coverage. 
 
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 the record indicates that the enrollee is improving but still require acute care services 
before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting authorization to go to 
rehabilitation. The Plan denied your request. The Plan says admission to an IRF was denied as not meeting 
criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled nursing facility level 
of care was offered. 
 
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 weakness after recent bilateral knee arthroplasty. 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. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the hemodialysis procedures with physician 
evaluation provided from February 11, 2022, to February 21, 2022. 
 
You asked the Plan to waive the cost share for the dialysis procedures. You say that this service should be 
covered 100% with no copay required. 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 20% 
coinsurance for outpatient dialysis treatments. The combined allowed amount is $215.07 x 20% coinsurance = 
$43.02. 
 
You have been asked to pay a 20% coinsurance for outpatient dialysis treatments. The hemodialysis procedures 
fall within the Services to Treat Kidney Disease 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 cost share for the hemodialysis procedures with 
physician evaluation provided from February 11, 2022, to February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of 
RFA to the SI joint have not been demonstrated in peer-reviewed literature. 
 
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 RFA to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 71-year-old male with a history of low back pain/chronic left 
sacroiliac joint pain/sacroiliitis, without radiation since 2019. He has tried physical therapy, oral steroids, 
NSAIDs, and lumbar epidural steroid injections without sufficient relief.  The enrollee is status post left SIJ 
injection on June 22, 2021, which provided >80% relief for nearly 8 months. The enrollee's neurosurgeon 
recommended a "radiofrequency ablation (RFA) to the sacroiliac joint (SIJ) to avoid surgery."  
 According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis 
and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. 
Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. 
 
The requested SIJ RFA under imaging guidance has not been proven effective and is considered experimental/ 
investigational. The review has determined that the requested left SI joint RFA 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam. 
 
You asked the Plan to pre-approve Octagam. The Plan denied your request. The Plan says the record does not 
show the enrollee has tried the preferred drug Privigen and it hasn't worked. 
  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 Octagam. Our reviewer says that the 
records do not contain documentation of trial and failure of Privigen. Our physician reviewer found that the 
documentation does not support that Privigen would likely be less effective or would likely have adverse 
effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Octagam have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic device on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for prosthetic device. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 50% 
coinsurance for out-of-network prosthetic device at prosthetics provider. Devices (other than dental) that 
replace all or part of a body part or function. These include but are not limited to: colostomy bags and supplies 
directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses 
(including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and 
repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or 
cataract surgery  see "Vision Care" later in this section for more detail. The provider billed in the amount of 
$17,261.80 and the allowed amount is $11,567.85. The Plan paid $5,783.96. $11,567.85 x 50% = $5,783.92. 
 
 You have been asked to pay a 50% coinsurance for prosthetic device. Prosthetic device falls within the 
Prosthetic devices and related 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 coinsurance 
for prosthetic device on October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan from an out-of-
network provider. 
 
You asked the Plan to pre-approve these services. You say that you need the CT scan for follow up after a 
cancer diagnosis four years ago. The Plan denied your request. The Plan says the services are available from 
network providers. 
 
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 
a computed tomography (CT) scan from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic sleeve gastrectomy. 
 
You asked the Plan to pre-approve laparoscopic sleeve gastrectomy. You say that you will not be able to lose 
the weight fast enough to get knee surgery. You said that you are using a walker and your knee is bone on 
bone. The Plan denied your request. The Plan says you do not meet Medicare criteria for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy is 
contraindicated (and therefore non-covered) for patients who require home oxygen therapy. Records from your 
pulmonologist on February 15, 2022, state that you were advised to use supplemental home oxygen when you 
sleep.  There are no more recent records showing that you are not using the home oxygen as recommended by 
your pulmonologist. That is why, at this time, you do not meet Medicare criteria for this surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laparoscopic sleeve gastrectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laparoscopic sleeve gastrectomy.
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 he enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is still acutely ill and requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules 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 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.