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

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the clinical 
effectiveness in the absence of ring sideroblasts have not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 physician reviewer found 
that the enrollee has a diagnosis of refractory anemia in myelodysplastic syndrome without ring sideroblasts.  
Reblozyl is not FDA-approved for the enrollees condition. The requested use of Reblozyl is not supported by 
one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The 
requested use is not listed as not indicated, not supported, or not recommended in any of the compendia. The 
use does not meet Medicare criteria. Therefore, the drug is not safe and effective and otherwise reasonable and 
necessary for 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the orthopedic surgeon told you that 
the nerve block is the best option based on the radiological evidence. The Plan denied your request. The Plan 
says genicular nerve blocks are considered investigational and not medically necessary for the treatment of 
chronic knee pain. 
 
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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve radiofrequency ablation of the right knee is not medically reasonable or 
necessary. Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency 
ablation are considered investigational for the treatment of chronic knee pain.  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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
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 enrollee needs IRF care to help him improve his 
current state of well-being and quality of life. The Plan denied your request. The Plan says criteria for 
admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can 
be provided at a lower level of care. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro orthotic. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will improve the long 
term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use or that this 
device will increase  participation in bimanual activities. 
 
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 MyoPro orthotic have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthotic (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that your life is in danger by being discharged 
from the hospital and you need the SNF admission. The Plan denied your request. The Plan says the SNF 
admission is not medically necessary, and your needs can be met at a different setting such as home with home 
health, in residential care, or home with close follow-up with their doctor. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not require any skilled 
nursing services daily at an inpatient level of care. The medical record does not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. There is no 
documentation which shows that daily skilled services are required. You are walking household distances with 
a 2-wheeled walker with contact guard assistance and is contact guard assist for transfers. As a practical matter, 
you do not require the services on an inpatient basis, at a SNF level of care at the time of discharge from the 
hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the enrollee is in danger of going home 
because they live by themself. You also say that the enrollee cannot get up and walk safely by themself. The 
Plan denied your request. The Plan says the enrollee does not require daily skilled nursing services. 
 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 admission. Our reviewer says that the enrollee did not 
meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that 
require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF admission have not been met. Specifically, the file does not indicate that you require daily 
skilled services. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility 
(SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 and 64634). 
 
You asked the Plan to pre-approve the destruction by neurolytic agent (64633 and 64634). The Plan denied 
your request. The Plan says your request does not meet the criteria for medical necessity. 
 
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 destruction by neurolytic agent 
(64633 and 64634). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the request exceeds criteria of no 
more than 2 radiofrequency ablation sessions per rolling 12-month period. 
  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 destruction by neurolytic agent (64633 and 64634) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent (64633 
and 64634).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic physical therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the aquatic physical therapy. You say that the only provider within 20 miles 
of your house is out-of-network. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 the aquatic physical therapy. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the documentation did not reveal extenuating factors that 
requires aquatic therapy with an out of network provider. There is no evidence that you are unable to 
participate in land based physical therapy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the aquatic physical therapy have not been met.  
 
The Plan has network providers available who can provide the land based physical therapy. We found no 
exception that would require the Plan to pre-approve the aquatic physical therapy. Therefore, we decided that 
the Plan does not have to pre-approve aquatic physical therapy to be provided by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no record of contact with the doctor after a recent six-week trial of treatment that 
failed to improve symptoms. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found reflexes are normal, and 
no reg flags are present. A report of the cervical spine x-ray was not included. The doctor has prescribed an 
exercise program, but there has been no monitored six week trial of physical therapy occurring. Absent a red 
flag, and absent of six week trial of physical therapy, the medical necessity of the requested MRI has not yet 
been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
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 this is not medically necessary. The Plan denied your 
request. The Plan says this 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy or can tolerate the therapy on an intensive IRF level. 
 
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: 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 you have realistic therapy goals for getting back to a 
community setting. The Plan denied your request. The Plan says treatment will not be better than treatment at a 
skilled nursing facility. 
 
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 documentation does not support that you require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that you are reasonably expected 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you need an IRF admission. The Plan denied your 
request. The Plan says according to the available records, you do not meet all the required Medicare criteria for 
admission to an IRF. 
 
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 complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the services. You say that you are having trouble breathing and you have 
not seen the cardiologist yet for your heart failure. The Plan denied your request. The Plan says there is no 
documentation that shows that a skilled service is required. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 medically reasonable or necessary. Our physician reviewer found the records do not 
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to 
improve your condition, or to establish/perform a maintenance program to maintain your condition and/or 
prevent deterioration. The patient had no complex wound care, enteral feedings or other skilled nursing need. 
You have had education on medication management and medical condition. The requested three more skilled 
nursing 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99214) to be provided by an out-of-network (OON) provider.
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 admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for SNF admission. 
 
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 you do not require skilled nursing services, 
but you would likely benefit from skilled therapy services.  The doctor says that the documentation does not 
support that it is medically necessary for these skilled therapy services to provide provided daily on an inpatient 
basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.