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

We decided that the Plan does not have to pre-approve Ogivri 420 mg vial.
You asked the Plan to pre-approve Ogivri. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Ogivri. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates
that the enrollee has esophageal adenocarcinoma. The requested medication is a new start. The provided
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service
cannot be 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 Ogivri have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ogivri 420 mg vial.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.
You asked the Plan to pre-approve Eliquis. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says this drug is not covered under the Plan's medical
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.
Benefits for Eliquis 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require 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 that the enrollee appears to be improving and should only require short-term
additional acute care services that may be continued safely at the current facility for now. The enrollee does not
require services at the LTACH that are not already available at the current facility. We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require 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 that the enrollee appears to be improving and should only require short-term
additional acute care services that may be continued safely at the current facility for now. The enrollee does not
require services at the LTACH that are not already available at the current facility.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that the requested injection is medically necessary. The
Plan denied your request. The Plan says that the requested Zilretta injections have not been found to be safe
and effective for repeat use.
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 Zilretta. Our reviewer says that the
requested drug, Zilretta, is medically necessary. Our physician reviewer found the documentation support that a
repeat administration of Zilretta is medically reasonable and necessary for the enrollee. The reviewer found that
additional administration of Triamcinolone acetonide has been shown to result in a similar magnitude and
duration of clinical benefit as the first injection and has been shown to be well-tolerated. Repeat administration
has been shown to be well-tolerated, with no unexpected adverse effects, post-injection flares, or radiographic
evidence of deleterious effects on cartilage or other elements of joint structure. Therefore, the reviewer found
that the requested drug is safe and effective 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 Zilretta have been met. Specifically, the file shows that the requested drug is
safe and effective for the enrollee. Therefore, we decided that the Plan has to pre-approve 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam.
You asked the Plan to pre-approve Temazepam. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Temazepam
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyepti.
You asked the Plan to pre-approve Vyepti. You say that the requested drug is necessary. The Plan denied your
request. The Plan says the criteria for coverage has not been met.
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 Vyepti. Our reviewer says that the
requested drug, Vyepti, is not medically necessary. Our physician reviewer found the documentation provided
does not support that the Vyepti is medically reasonable and necessary for the enrollee's migraine treatment as
defined by Medicare criteria. The reviewer found that the documentation indicates the Vyepti will be used
concurrently with Botox injections which is not consistent with the health plan's approved Medication Policy
Manual for Vyepti. The reviewer also found that the documentation does not support that the Vyepti is safe and
effective for the enrollee's migraine treatment as defined by Medicare 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 Vyepti have not been met.
Specifically, the file shows that Vyepti will be used concurrently with Botox injections which is not consistent
with the health plan's approved Medication Policy Manual. Therefore, we decided that the Plan does not have
to pre-approve Vyepti.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan
states the services the enrollee needs could be provided in another setting, such as an acute rehabilitation
facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 health plan's denial of LTACH coverage should be upheld. The enrollee is
currently undergoing treatment at an ACH for chronic wounds. The enrollee is not intubated/ventilated. There
is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are
licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The
enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing LTC 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third opinion on your medical condition to be
provided by an OON provider.
You asked the Plan to pre-approve a third opinion. You say that this is medically necessary. The Plan denied
your request. The Plan says it is not medically reasonable for you to see another provider regarding your
condition.
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 provider at issue in this case is not a network provider with the Plan. 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 third opinion. Our reviewer says that the requested OON provider visit is
not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-year-old female
requesting a third orthopedic surgery provider opinion with an OON orthopedic surgery provider. The two
prior orthopedic surgeons she has been referred to for consultations to evaluate left hip osteoarthritis are innetwork,
and both providers recommended she undergo left total hip arthroplasty.
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 third opinion have not been met.
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 a third opinion. Therefore, we decided that the Plan
does not have to pre-approve a third opinion on your medical condition to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device.
You asked the Plan to pre-approve the requested device. You say that the basic pump would be ineffective. The 
Plan denied your request. The Plan says the enrollee has not failed a basic pump.
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device is only covered 
under certain medical indications. 
We looked at the file and Medicare rules. The records provided do not show a four-week trial of a basic pump. 
Based on this information, we decided that Medicare rules for coverage of the requested device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 enrollee does not meet criteria for IRF admission. 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 was admitted for congestive heart failure and respiratory failure and was discharged home in December of 2021. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prochlorperazine.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prochlorperazine.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone/Acetaminophen tablet.
You asked the Plan to pre-approve Hydrocodone/Acetaminophen. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve
Hydrocodone/Acetaminophen tablet.
Benefits for Hydrocodone/Acetaminophen 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the chest.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says the records do not
show how an MRI will help.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our physician reviewer found
that you have abdominal pain with palpable abdominal mass. An ultrasound was equivocal. A computed
tomography (CT) scan of the abdomen and pelvis were approved. There was insufficient support made for an
MRI of the chest at this time. The approved CT of the abdomen/pelvis should suffice in investigating the
mass/abdominal pain. Also, there were no signs or symptoms in the chest area warranting imaging. A chest xray was not performed, which should come before advanced imaging of the chest. Therefore, this request for an
MRI of the chest will be considered not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria. 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your functional improvement had plateaued by February 18, 2022 and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says you can walk over 20 feet with an assistive device, and you have no skilled
needs that have to be provided in an inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled
nursing needs or skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of your condition. At
this point, your care needs are custodial and, as a practical matter, can 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
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 you do not meet the criteria for coverage.
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 you do not treat with insulin three or more times per day. 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 continuous glucose monitor (CGM) and supplies.