Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint injections. 
 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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found the 
enrollee has evidence of radiculopathy.  The review has determined that the enrollee does not meet the above 
LCD criteria for the requested facet joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #29. 
 
You asked the Plan to pre-approve a crown. You say that you did not receive a crown on July 30, 2021. You 
also say the services for a crown were not done because the office was behind schedule. The Plan denied your 
request. The Plan says this service is covered under your benefit package, but exceeds the maximum count 
allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown once 
per tooth, every five plan years. 
 
We looked at the file and Medicare rules. The EOC confirms that you receive one crown per tooth every five 
plan years. The records show that you had a crown procedure on tooth #29 on July 30, 2021, therefore, you 
have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's 
rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crown (D2740) for tooth #29.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the documentation does not support that it is 
medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a 
combination of these services) on a "daily basis" on an inpatient basis, in a skilled nursing. The documentation 
supports those services may be provided at a lower 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 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pain management injections. 
 
You asked the Plan to pre-approve pain management injections. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients that meet specific criteria. 
 
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 pain management injections. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the request is for repeat 
radiofrequency ablation of L4-l5 and L5-S1, not lateral sacral branches. The notes indicate radiofrequency 
ablation of the lumbar facets was performed on January 10, 2020, and the pain has returned. The request is 
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 pain management injections have been met. Therefore, we decided that the Plan 
has to pre-approve pain management injections.  
 
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 home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
Life2000 system is not medically necessary. This system is not a true ventilator. It is not capable of providing 
full ventilatory support. There is inadequate evidence that this device is beneficial in the treatment of chronic 
obstructive pulmonary disease (COPD). Also, this enrollee does not meet criteria for coverage of nighttime ventilatory assistance. The enrollee has 
COPD, but there is no documentation of chronic CO2 retention. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 9, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the documentation provided does not indicate the enrollee as being hypoxic, with 
vital signs abnormality or suffering from any signs and symptoms associated with pulmonary embolus. The 
documentation provided does not substantiate the enrollees need for inpatient hospitalization stay relating to 
the diagnosis of shortness of breath. Therefore, the reviewer found that the record did not show that at the time 
of inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cardiovascular Panel (81185, 81286, 81400, 81413, 
81414, 81442 and 81479) provided on August 16, 2021. 
 
You asked the Plan to pay for the Cardiovascular Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the member and provider. 
 
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 pay for the Cardiovascular Panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation is unclear as to the clinical indications for this testing. It has not 
been established that this testing would impact the management and outcomes of this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Cardiovascular Panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the Cardiovascular Panel (81185, 81286, 81400, 81413, 81414, 81442 and 
81479) provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the last appointment with the treating physician was more than six months ago. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 have had an 
in-person visit with their treating physician within the last six months to assess adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of 
the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron 8mg tablets. 
 
You asked the Plan to pre-approve Ondansetron. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says Part B coverage criteria has not been met. 
 
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, except when used as a full therapeutic replacement for IV anti-emetic drugs that would have 
been administered at the time of the cancer chemotherapy treatment. In this case the record does not show this 
is to replace IV anti-emetic drugs. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 8mg tablets.  
 
Benefits for Ondansetron 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker implantation (33274). 
 
You asked the Plan to pre-approve the leadless pacemaker implantation. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says this type of pacemaker is non-covered 
outside of clinical trials. 
 
The Plan must follow Medicare rules. Medicare rules say that Leadless pacemakers are non-covered when 
furnished outside of a Medicare approved CED study. 
 
We looked at the file and Medicare rules. No documentation has been provided to show the enrollee is part of a 
Medicare approved study or trial. Based on this information, we decided that Medicare rules for coverage of 
the leadless pacemaker implantation have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a leadless pacemaker implantation (33274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Review of the file shows the claim was billed with an 
inappropriate place of service 11. According to claims history, the specimen was obtained in an Assisted 
Living Facility (ALF). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 25, 2021.
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 an LTACH admission is the safest 
discharge plan for the enrollee, and it allows for the highest potential level of recovery. The Plan denied your 
request. The Plan says the criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that long term acute care hospital (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 is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the 
current ACH until such time no acute services are required.  Our physician reviewer also found that the 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee has been 
improving with outpatient therapy and does not require physician oversight. The Plan also says that there is no 
indication for an inpatient rehabilitation 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 enrollee does not require the intensity of services provided at an IRF. Our 
reviewer also found that specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you need Feraheme to treat your condition. The 
Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the 
Plan requires a trial of Infed and Venofer before it will approve Feraheme. 
 
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. Medicare covers Part B medications when they are reasonable and necessary but allows health plans 
to implement step therapy criteria. 
 
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 did not submit a copy of the applicable Evidence of Coverage (EOC) 
for your case. Without this, we cannot determine whether the Plan has implemented step therapy criteria that 
might apply to Feraheme. Therefore, the Plan has not shown that its decision to deny Feraheme is correct 
according to Medicare rules and your contract with the Plan. Therefore, we decided that the Plan has to pre-
approve use of Feraheme.  
 
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 continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you are not stable or 
safe for discharge. You say that you are still making medication changes and are at risk to harm yourself. The 
Plan denied your request. The Plan says the requested inpatient psychiatric care is not medically necessary as 
the enrollee's condition has stabilized to the baseline of his dementia. 
 
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 continued inpatient psychiatric services. 
Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of March 15, 2022, forward. Our physician reviewer found the enrollee 
was involuntarily admitted to the acute inpatient psychiatric hospitalization on March 8, 2022, with Major 
Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon review the records provided 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, no auditory or visual hallucinations and no aggressive 
behaviors. The enrollee was compliant and cooperative with treatment. 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 as he did not have any suicidal or homicidal thoughts, hallucinations or 
aggressive behaviors. It does not appear that the services for the dates in question are reasonably expected or 
medically necessary to improve the enrollees condition or for the purpose of diagnosis.  The enrollee 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 continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services.