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

We decided that the Plan does not have to pre-approve Rosuvastatin 20 mg tablet.
You asked the Plan to pre-approve Rosuvastatin. You say that this drug is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested drug is not covered under the
enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rosuvastatin 20 mg tablet.
Benefits for Rosuvastatin may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (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 rules for IRF care 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 that the patient was admitted for nonsurgical management of an L4 vertebral fracture.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is
no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable
expectation that this patient 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 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says you do not meet Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care after January 5, 2022.
You asked the Plan to pre-approve continued inpatient mental health. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.
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 continued inpatient mental health. Our reviewer says that the requirements for coverage of inpatient care have not been met. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time beyond previously approved date as he was not showing any dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors. He was not showing any acute threats of safety. The patient was cooperative and compliant with medication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care after January 5, 2022.
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 IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care 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 that the patient was admitted for weakness and a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multipletherapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin injections.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a past medical history of endocarditis and a stroke with right spastic hemiparesis. Treatment with Xeomin injections 100-200 units to the right lower extremity knee extensors and ankle plantar flexors under electromyography (EMG) guidance has been requested. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Xeomin injections to the lower extremity meet Medicare criteria for medically reasonable and necessary for the patient. Xeomin is Food and Drug Administration approved for upper limb spasticity but it has no indication for lower limb spasticity. 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 Xeomin injections.
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 In this case the enrollee was admitted with peritonitis from perforated gastric ulcer
and required operative intervention. The record indicates that the enrollee subsequently had acute respiratory
failure and although is improving still requires ongoing acute care services. The enrollee continues to receive
acute care services, and these have not been denied. The medical record does not indicate that the enrollee
requires services that she is not currently receiving but that would be available at the LTACH facility. The
elements of the coverage rules are not satisfied. The requested service cannot be recommended
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three office visits to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.
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 three
office visits to be rendered by the out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy criteria have not been met.

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 indicated in the submission of the case file that they received medical records and referenced these records in their decision. However, medical records have not been submitted for review. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pre-approve Prolia.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard - hard appliance, full arch (D9944).
You asked the Plan to pre-approve a mouth guard. You say that you need this dental service. The Plan denied
your request. The Plan says you will exceed the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a mouth
guard when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The Plan provided documentation showing that an occlusal guard
provided December 9, 2021, was previously covered by the Plan. Based on this information, we decided that
the Plan's frequency limit for coverage of a mouth guard would be exceeded. Therefore, we decided that the
Plan does not have to pre-approve an occlusal guard - hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower
denture (D5120).
You asked the Plan to pre-approve the dental services. You say that you were let go from your previous dentist
office. You also say that you need new dentures. The Plan denied your request. The Plan says dentures are
covered once every 60 months. The Plan also says that the frequency limit has been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for dentures that you received on
December 15, 2020.
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a
complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.
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 stage IV breast cancer
with bony metastases. She has not tried and failed the Plan's required drugs, zoledronic acid and pamidronate.
The records do not show that the required drugs would be contraindicated or less effective; therefore, Xgeva 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 Xgeva.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orthovisc injection.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there
are no imaging studies of the left knee.
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.
The file shows that Orthovisc injections of the right and left knee were requested. The Plan has agreed to pre-
approve a right knee injection. 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
left knee injection. Our physician reviewer found that the enrollee has bilateral osteoarthritis of the knees. She
has tried physical therapy, non-steroidal anti-inflammatory drugs, and steroid injections. However, the imaging
reports submitted are only of the right knee. There is no imaging of the left available for review. Lacking this
documentation, the request is deemed not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Orthovisc injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ankle foot orthosis (L1960), an addition to the lower
extremity (L2340), a foot insert (L3020), and a shoe lift (L3310) to be provided by an out-of-network (OON)
provider.
You asked the Plan to pre-approve an ankle foot orthosis, an addition to the lower extremity, a foot insert, and a
shoe lift. You say that you would like the Plan to consider an exception and allow your long time provider to
provide this service. You also say you would lose the years of experience that this provider has developed
supporting your very unique needs. The Plan denied your request. The Plan says out of network services are for
emergencies and/or if there is not a contracted specialist in network. The Plan also says that this provider is not
a contracted vendor within your medical group, and there is a medical provider in network that is able to
provide your medical device. The Plan also says that it has been longer than 6 months since you have last seen
this provider.
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
an ankle foot orthosis (L1960), an addition to the lower extremity (L2340), a foot insert (L3020), and a shoe lift
(L3310) to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network (OON) tertiary level of care referral.
You asked the Plan to pre-approve an OON tertiary level of care referral. You say that an OON tertiary level of
care referral is medically necessary. The Plan denied your request. The Plan says an OON tertiary level of care
referral is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an OON tertiary level of care referral.
Our reviewer says that an OON tertiary level of care referral is not medically necessary. Our physician
reviewer found based on the documentation provided, the Plan's denial is medically justified on the basis that it
is offering adequate care to meet the enrollee's medical needs through referral within the enrollee's network.
There is not anything unique about the enrollee's condition that that would make it medically necessary for her
to see the requested out-of-network provider. There are no clinical trials listed on clinicaltrial.gov for
pancreatic cancer that is locally advanced but not metastatic currently open at the OON facility. The Plan has
shown that they have in-network providers who meet the Standards of Care required for treatment of the
enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an OON tertiary level of care referral have not been met. Therefore, we decided
that the Plan does not have to pre-approve an out-of-network (OON) tertiary level of care referral.
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 that the patient was admitted for syncope and a pelvic fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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.