Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an additional 12 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee does not require the unique skills of a professional 
therapist to provide treatment safely and effectively. The services can be safely and effectively performed only 
by a therapist, or by or under the supervision of a therapist.  The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design, or deliver a program to maintain the enrollees current condition or to prevent or slow 
further deterioration. The enrollee can transition to a home exercise program with the approved therapy 
therefore the remaining 6 visits are 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy visits.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the documentation does not support medical necessity for admission to an IRF. 
You have no current medical complexity or rehabilitation nursing needs and are highly functional. While you  will benefit from physical therapy and occupational therapy, your rehabilitation needs can be safely met in an 
alternate and low intensity setting such as in -home with 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 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: 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 LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 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 Plan has approved ongoing care in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need the next level of care to see if 
any progress can be made. You also say that the services from LTACH are very important for your care. The 
Plan denied your request. The Plan says the services you need 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 you appear to be more stable but not improving further with current treatment and 
should only require short-term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for a lower level of care. You do not require services at the LTACH that are 
not available at the current 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 
admission. The Plan denied your request. The Plan says LTACH services are not medically necessary. 
 
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 appears to be improving but still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the currently 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve occipital nerve block services. 
 
You asked the Plan to pre-approve occipital nerve block services. You say that this procedure is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that there is 
no proof in the current peer-reviewed literature to support the requested occipital nerve block for the enrollee's 
condition. 
 
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 occipital nerve block services. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has had a posterior fusion at C3-C6. The enrollee then 
developed left sided neck pain and decreased mobility of her neck. They take Gabapentin, Tylenol and 
Cymbalta for pain. They have had physical therapy and has had Trigger point injections in the neck as well as 
prior occipital nerve blocks. They also had left atlantoaxial joint injection services which gave her 75% pain 
relief. She has the diagnoses of occipital neuralgia, cervicogenic headaches and trigger points. In this case, 
occipital nerve block is a standard therapy for occipital neuralgia. The requested services can be considered 
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 occipital nerve block services have been met. Therefore, we decided that the 
Plan has to pre-approve occipital nerve block services.  
 
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 an electrical connector for a power wheelchair (E2310). 
 
You asked the Plan to pre-approve the electrical connector for a power wheelchair. You say that this feature is 
medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
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 electrical connector for a power 
wheelchair. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found records show the enrollee has adequate upper body strength to 
manage standard switches. The electrical connector to allow power functions to be operated from the single 
controller is 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 the electrical connector for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an electrical connector for a power wheelchair (E2310).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo (Q5120). 
 
You asked the Plan to pre-approve Ziextenzo. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ziextenzo. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Ziextenzo. Our physician reviewer found the provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our 
reviewer also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo (Q5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
 
 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. The Plan denied your request. The Plan says this drug is not 
considered to be used for a medically accepted indication. 
 
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 Udenyca. Our reviewer says that 
Udenyca is not medically reasonable and necessary for the enrollee. Our physician reviewer found the FDA has 
not stated that the requested drug is indicated for the enrollee's condition. Our reviewer also found that the 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve PalinGen or PalinGen XPlus, per sq cm. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there have been no failed attempts at conservative therapy. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request is necessary in order to avoid a surgical procedure. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve PalinGen or PalinGen XPlus, per sq cm.  
 
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: 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the SNF services do not meet the requirements for 
approval. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is receiving therapy in an intensive rehabilitation facility. The enrollee 
had reached capacity to perform activities of daily living, walk and transfer to a standby assist. The enrollee 
does not require daily skilled therapy. Admission to skilled facility is not medically necessary per Medicare 
Chapter 8. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it appears that neurolysis of peripheral nerves is most commonly indicated by a clear 
mononeuritis, which is not the case in this patient's situation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genicular nerve blocks and genicular nerve ablation are considered investigational and not medically 
necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the genicular nerve ablations are considered 
experimental/investigational in nature. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that this is necessary for activities outside of your 
home. The Plan denied your request. The Plan says this item is not covered for use outside of home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient mental health care provided to the enrollee from October 
11, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the stay was medically 
necessary. The Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 
Our physician reviewer found based upon review the records provided for the admission of this enrollee does 
meet criteria for acute inpatient mental health treatment as although this enrollee was not shown to be a danger 
to their self or others, no auditory or visual hallucinations, the enrollee was labile, tangential and circumstantial 
with paranoia and delusional thinking. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient mental health care provided to the enrollee from October 11, 2022, 
forward.  
 
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.