Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplement device. 
 
  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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires 
a trial of drugs Durolane, Monovisc, and Synvisc-One before they will approve the requested drug. Our 
reviewer found that in this case, has not the patient tried and failed the required drugs. Our physician reviewer 
also found that there is no documentation provided indicating that the Plans required drugs would likely be 
less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
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 criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 IRF admission is not medically necessary based on lack of medical complexity, 
and lack of acute rehab nursing needs. Our reviewer found that the documentation does not support the 
necessity for an admission to an IRF. Our physician reviewer also found that your rehabilitation needs can be 
met safely at a lower intensity and alternate 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 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 an inpatient hospital stay. 
 
You asked the Plan to pre-approve the inpatient hospital stay. You say that the enrollee's condition is very 
serious. You also say that the enrollee had COVID-19, has gotten worse, and medications are not working 
anymore. The Plan denied your request. The Plan says the criteria for an admission to the hospital have not 
been met. 
 
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 pre-approve the inpatient hospital stay. 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 record does not show that at the time of inpatient admission the admitting 
physician reasonably expects that the patient's necessary hospital care will 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 the inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have post-
laminectomy syndrome and sacroilitis. The requested RFA of the SI joint is considered 
experimental/investigational in nature for your condition, as there is insufficient literature establishing the 
safety and effectiveness of the procedure. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a high risk cancer diagnosis. 
The Plan denied your request. The Plan says that this is not the standard of care for the enrollee's treatment. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Proton therapy 
would arguably exceed need for this patient. Proton therapy may or may not be better than IMRT/IGRT. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Proton Beam Radiation Therapy (PBRT) for the enrollee.
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 physical therapy, occupational 
therapy, and complex wound care. You also say that you feel the enrollee would benefit from daily physician 
oversight. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Our reviewer found 
that specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services. Our 
physician reviewer also found that your care needs can be met 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 1, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the POS rules used by the 
Plan are only applicable to lab tests paid on the Physician Fee Schedule (PFS), and do not apply to this service. 
The Plan denied your request. The Plan says the POS code used is not appropriate as it does not reflect the 
location in which the sample was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on August 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional feature for a prosthetic knee (L5845) for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of knee does not use this code. 
 
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 the available medical records from the enrollee's medical provider do not document the necessity of 
the additional feature for the prosthetic knee (endoskeletal knee-shin system, stance flexion feature, adjustable, 
L5845) as required 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional feature for a prosthetic knee (L5845) for the enrollee.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with acute hypoxic and hypercapnic respiratory failure in the setting of a myasthenia 
gravis crisis. He continues to receive acute care services. The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. LTACH 
services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Orthovisc, Synvisc, or Synvisc-One. The records do not show 
that the required drugs would be contraindicated or less effective; therefore, GenVisc 850 is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on June 29, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you were compliant with Medicare regulations for 
billing the date of service and place of service. The Plan denied your request. The Plan says the denial of 
payment for this testing is correct, because the documentation submitted does not support the Place of Service 
(POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the POS code 81  indicating an independent lab setting  is not appropriate for 
this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on June 29, 
2021.
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 the SNF services. The Plan denied your request. The Plan says the Skilled 
Nursing Facility (SNF) services you are requesting 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 the SNF services. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve the SNF stay. You say that the enrollee needs to have rehabilitation before 
going home. The Plan denied your request. The Plan says the SNF services you are requesting 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 the SNF stay. Our reviewer says that 
the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does 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 the SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) stay.
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 the SNF services. The Plan denied your request. The Plan says this request 
is not medically necessary. 
 
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 services. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 the 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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy services provided in a nursing home on May 15, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the records support the services 
rendered. The Plan denied your request. The Plan says that no appeal decision was made due to missing the 60-
day time frame. 
 
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. 
 
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 has not provided a denial rationale for the services at issue due to 
missing the appeal time frame. As such, we find that the denial of this service has not been substantiated. 
Therefore, we decided that the Plan has to pay for the psychotherapy services provided in a nursing home on 
May 15, 2021.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will need intensive rehabilitation in 
order to return home. The Plan denied your request. The Plan says authorization denied because IRF is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as 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 the enrollee is 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.