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

 
We decided that the Plan does not have to pre-approve use of an implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that an implantable cardiac monitor 
would help in determining if the enrollee is getting arrhythmia versus bracycardia or sinus pause so you can 
medically manage them. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for an implantable loop recorder. 
 
The Plan follows Medicare rules. Medicare rules state that an implantable loop recorder may be covered under 
certain conditions. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an implantable loop recorder. Our 
physician reviewer found the enrollee has no history of atrial fibrillation, nor were atrial fibrillation or any 
symptomatic cardiac arrhythmia noted on electrocardiogram monitoring. A recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an implantable loop recorder was not superior to 
usual care in reducing stroke or systemic embolism among patients at high risk of stroke but without a proper 
known prior history of atrial fibrillation. This is not medically appropriate and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialty care. You say that the in-network provider does not prescribe the 
medication you need. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this provider is out-of-network with the Plan and you can be treated by an in-network 
specialist. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pain management treatment to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EpiFix (Q4186 x60) and application of skin substitute 
graft (15275 x5). 
 
You asked the Plan to pre-approve EpiFix and application of skin substitute graft. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 EpiFix and application of skin 
substitute graft. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that the EpiFix and application of a skin 
substitute graft at issue in this case meet Medicare criteria for safe and effective. Provided records clearly 
document slow but progressive reduction in the volume and area of the ulcer in this case with standard 
treatment from April 2022 through July 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EpiFix and application of skin substitute graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve EpiFix (Q4186 x60) and application of skin substitute graft 
(15275 x5).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 age-related 
osteoporosis without osteoporotic fracture. She has not tried and failed the Plan's required drug, zoledronic 
acid. The records do not show that the required drug would be contraindicated or less effective; therefore, 
Prolia 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 Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the Medicare guidelines for IRF 
services. The Plan denied your request. The Plan says the records do not show that the enrollee is able to take 
part in 3 hours of therapy 5 days per week, nor do they need an intensive team for their care, nor does the 
enrollee need to be seen by a rehabilitation doctor 3 times per week. The services the enrollee needs can be 
provided safely in other settings, for example, a skilled nursing facility, home with home health services or 
home with outpatient therapy. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of authorization for 
acute inpatient rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition they do not meet the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found the enrollee is currently living at home and is wheelchair bound since spine 
surgery. The enrollee had an L5- S1 Anterior Lumbar Interbody Fusion (ALIF) and an L1-S1 Posterior Fusion 
on 5/24/22 and has been receiving home health care services since 7/15/22. The enrollee is medically stable 
and comorbid conditions are all stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical 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 Feraheme. 
 
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 iron deficiency anemia. 
She has not tried and failed the Plan's required drug, Venofer. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Feraheme 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 Feraheme.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
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 or Supartz FX. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Synvisc 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 Synvisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pradaxa 150mg tablets. 
 
You asked the Plan to pre-approve Pradaxa. You say that Pradaxa is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B 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 Pradaxa 150mg tablets.  
 
Benefits for Pradaxa 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that BiPAP has not been successful in 
treating the enrollee. The Plan denied your request. The Plan says settings that could be delivered by BiPAP is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ventilator. Our physician 
reviewer found that the enrollee has asthma, obstructive sleep apnea, and tracheobronchomalacia. The noted 
diagnoses are not amongst those for which coverage is available under the rules. Furthermore, the provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan 
has indicated such a device is covered. Therefore, the requested ventilator 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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve eye care. 
 
You asked the Plan to pre-approve eye care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that this service is not covered by Medicare. 
 
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. Although the Plan claims that this service is not covered by Medicare, the Plan 
has not provided any evidence that the requested service is actually excluded from Medicare coverage. The 
Plan assigned procedure code A9270 to the requested service but has not provided supporting evidence to show 
that A9270 is the appropriate code for the requested service. The Plan has not provided any other evidence or 
rationale to support a denial of authorization for this service. Therefore, the Plan has not shown that its decision 
to deny authorization for this service is correct or justified according to Medicare rules. Therefore, we decided 
that the Plan has to pre-approve eye care.  
 
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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have pain in your heels at the arch. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the network ophthalmologist is scheduling too 
far off. 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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
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 are appealing the denial of LTACH 
admission based on a medical necessity. The Plan denied your request. The Plan says the enrollee can receive 
the same services at the current level of 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 enrollee was admitted to the acute hospital with sepsis, hypotension, and acute 
respiratory failure. The enrollee was treated with antibiotics, wound care, heparin drip, tube feeds, mechanical 
ventilation support, drain replacement, and vasopressors. The enrollee appears to be more stable and improving 
and should only require short-term additional acute care services that can safely completed at the current 
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving 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 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 colorectal services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you are getting infected. The Plan denied your 
request. The Plan says there are providers in your network who can care for you. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
colorectal services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says Medicare rules have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox.  
 
Benefits for Botox 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new pair of eyeglasses in 2022. 
 You asked the Plan to pre-approve new eyeglasses. You say that you previously received eyeglasses in January 
of 2022, but you were recently diagnosed with diabetes and your eyesight has diminished since then. You need 
new glasses and a new prescription to see properly. The Plan denied your request. The Plan says you 
previously exhausted your eyewear benefit on January 14, 2022. This means you cannot get new eyewear 
covered by the Plan until January 14, 2023. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per year from your last date of service. 
 
We looked at the file and the Plan's rules. The record shows that you have already exhausted your benefit in 
2022 and are not eligible for new eyeglasses until January 14, 2023. Based on this information, we decided that 
the Plan's rules for coverage of new eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new pair of eyeglasses in 2022.