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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Part B step therapy requirements for Euflexxa.  
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the case file does 
not contain documentation of trial and failure of Synvisc, Durolane, and Gelsyn-3. The documentation does not 
support that Synvisc, Durolane, and Gelsyn-3 would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 a home ventilator. You say that a home ventilator is medically necessary 
and positive airway pressure therapy has failed to control the patient's multifactorial respiratory failure. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary. A bilevel positive airway 
pressure (BiPAP) device with average volume-assured pressure support (AVAPS) would meet the patient's 
needs. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the member does not appear to 
have the severity of illness that would justify the need for a home mechanical ventilator (HMV). Furthermore, 
there is no documentation to suggest a BiPAP with backup rate and AVAPS was utilized and failed that would 
otherwise necessitate the use of a home mechanical ventilator (HMV). The review has determined that this 
patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 lower limb prosthetic foot (L5968, L5981). 
 
You asked the Plan to pre-approve a K3 lower limb prosthetic foot. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for coverage. 
 
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 K3 lower limb prosthetic foot. Our 
reviewer says that the request exceeds your medical needs and is not medically necessary. Our physician 
reviewer found the documentation does not support that you require a K3 foot to meet your functional needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of K3 lower limb prosthetic foot have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a K3 lower limb prosthetic foot (L5968, L5981).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate rectal spacer (55874). 
 
You asked the Plan to pre-approve prostate rectal spacer. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare requirements for coverage, most notably the stage of disease requirement. 
 
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 prostate rectal spacer. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found records show that the enrollee does not have low or favorable intermediate prostate 
cancer risk group. The enrollee records also do not show the type of radiation treatment planned. The enrollee 
does not meet the coverage criteria for Prostate Rectal Spacer as cited above: Local Coverage Determination 
(LCD) Prostate Rectal Spacers L37485. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate rectal spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve prostate rectal spacer (55874).
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's condition is too medically complex for 
them to return home. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology provided on July 15, 2022. 
 
You asked the Plan to pay for intraoperative neurophysiology. You say that intraoperative neurophysiology 
was medically necessary. The Plan denied your request. The Plan says intraoperative neurophysiology is 
experimental. 
 
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 pay for intraoperative neurophysiology. Our 
reviewer says that the requested intraoperative neurophysiology is not considered medically reasonable and necessary. Our physician reviewer found that the enrollee was a then 70-year-old who underwent a right carotid 
endarterectomy with intraoperative neurophysiology on July 15, 2022. Currently, with no clear consensus on 
monitoring technique, choice should be guided by local expertise and complication rates. With reflection, best 
practice may dictate that a standard technique is selected as suggested above and this remains the default 
position for individual practice. Nevertheless, current techniques for monitoring cerebral perfusion during 
carcinoembryonic antigen (CEA) are associated with false negative and false positive resulting in inappropriate 
shunt insertion. The review has determined that the intraoperative neurophysiology at issue in this case was 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 intraoperative neurophysiology have not been met. Therefore, we decided that 
the Plan does not have to pay for intraoperative neurophysiology provided on July 15, 2022.
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 you are requesting an expedited reconsideration for 
the denial of a SNF admission. The Plan denied your request. The Plan says the criteria for admission to a SNF 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee 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 skilled nursing 
facility (SNF) setting. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs are custodial and can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revision of total hip arthroplasty (THA) (27134). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 service. Our physician reviewer 
found the detailed documentation is not evident regarding diagnostic imaging studies corroborating any 
loosening, fracture/mechanical failure of the prosthesis, displaced periprosthetic fracture, progressive or substantial bone loss, or bearing surface wear leading to symptomatic synovitis. Additionally, the 
documentation does not support recurrent or irreducible dislocation, infection, significant leg length inequality, 
significant audible noise, or adverse local tissue reaction. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the enrollee 
does not meet the coverage criteria detailed in the LCD. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the revision of total hip arthroplasty (THA) (27134).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the aide services. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the clinical documentation does not list any care plan in which the continued skilled services of a home health aide would 
be required. 
 
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24 trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional trips to 
physical therapy visits. The Plan denied your request. The Plan says the requested trips exceed your 
transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
24 trip limit.
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 the enrollee needs LTACH monitoring 
for their multiple medical issues, therapy services and monitoring of cardiac, renal and functional dysphagia. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does 
not require transfer to a long-term acute care hospital. 
 
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 recent notes describe the enrollee as responding to treatment, afebrile, without 
leukocytosis, on room air, and only requiring basic wound care, tolerating oral. The enrollee appears to be 
improving and should only require short-term additional acute care services that can safely be administered at 
the current facility. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Completion of treatment at the current facility is 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the magnetic resonance imaging (MRI) shows facet degenerative joint disease (DJD) and some 
stenosis. The cause of pain is unclear. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the CardioMEMS device. 
 
You asked the Plan to pre-approve implantation of the CardioMEMS device.. You say that the CardioMEMS 
device is Food and Drug Administration (FDA)-approved and medically necessary for this patient. The Plan 
denied your request. The Plan says implantation of the CardioMEMS device is not medically reasonable and 
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 implantation of the CardioMEMS 
device.. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found The CardioMEMS device was approved by the FDA in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of the CardioMEMS device. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of the CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
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 Hyalgan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has unspecified osteoarthritis. The documentation does not support that Hyalgan is 
not FDA-approved for the enrollees diagnosis of unspecified osteoarthritis, unspecified site. Its use is not 
supported by one of the major drug compendia, such as DRUGDEX Information System, the American 
Hospital Formulary Service Drug Information (AHFS-DI), Clinical Pharmacology, and/or Lexi-Drugs. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute rehab to optimize 
their level of functioning prior to returning home. You say that the enrollee requires interdisciplinary therapy. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can 
receive the care they need in another setting. 
 
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 meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services 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 IRF admission and services.