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

 
We decided that the Plan does not have to pre-approve Tizanidine HCL. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is necessary for the 
treatment of the enrollee's condition. The Plan denied your request. The Plan says the medication is not covered 
as a medical benefit under the Plan. 
 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 Tizanidine HCL.  
 
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS3D testing provided on September 7, 2021.  
 
You asked the Plan to pay for the WATS3D testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says experimental procedures are not covered.  
 
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 the WATS3D testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that WATS testing is not yet considered standard of care. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines specifically state that they only provide a conditional 
recommendation for WATS with low evidence, and that the cost-effectiveness is still 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 WATS3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS3D testing provided on September 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine outpatient mental health care office visits to be 
provided by an OON provider.  
 
You asked the Plan to pre-approve the mental health visits. You say that you have seen this provider for years 
and have built a rapport. The Plan denied your request. The Plan says you can transition to a network provider 
for these 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 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 
nine outpatient mental health care office visits to be provided by an OON provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Durolane, Monovisc, or Synvisc-One is required before alternatives can 
be considered. 
 
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 necessary. Our physician reviewer found the records show no trial of the plan preferred 
drugs, or any reason they would be unsafe or ineffective. 
 
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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 
8, 2023. 
 You asked the Plan to pre-approve SNF care after July 8, 2023. You say that the continued admission to a SNF 
is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 SNF care after July 8, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after July 8, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after July 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute (Q4158). 
 
You asked the Plan to pre-approve skin substitute. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found skin substitutes for pressure ulcers are considered investigational without strong evidence that it 
is 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 skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute (Q4158).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 continued inpatient hospital care. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you declined a discharge with the reasoning you are concern of housing 
situation (but declined other housing options). The review determined you did not have any acute care needs; 
therefore, you were stable for discharge on July 15, 2023, and has remained stable for discharge from hospital since that date. The review indicates that the items/services at issue in this case were 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 continued inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466) x3 months. 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
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 home ventilator. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in a volume assured pressure support (IVAPS) mode which is a modality which could be provided by a bilevel positive 
airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466) x3 months.
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 was previously independent and requires 
rehabilitation to regain the prior level of function. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for an IRF admission. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of the Plan, the enrollee may receive some of their covered services 
from out-of-network providers. Still, unless the enrollee is receiving emergency care, urgently needed care, flu 
shots, pneumonia shots, routine vision services, or kidney dialysis, the enrollees costs may be higher to see 
out-of-network providers than our network (plan) providers. If the enrollee chooses to receive care from out-of-
network providers, the enrollee will be using their Point-of-Service (POS) benefits, meaning your POS cost 
sharing will apply. 
 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 
surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance. 
 
You asked the Plan to pre-approve a radiofrequency ablation. You say that this procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a radiofrequency ablation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a radiofrequency ablation (RFA) of the sacroiliac joint is experimental for back pain, 
and more research is needed.  
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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve. 
 
You asked the Plan to pre-approve a surgical procedure. You say that the enrollee would prefer not to take 
opioids. The Plan denied your request. The Plan says this procedure/surgery is not medically necessary and is 
considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a surgical procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes, and no facet 
joint disease or foraminal stenosis. The cause of back pain is also not clear. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme.  
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied 
your request. The Plan says a trial of Venofer is required before alternatives can be considered. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drug, or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 20, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you say that the services were rendered in a nursing 
home where their company has an exclusive contract with the facility, and they are the only providers who are 
able to treat patients via teleconference. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision services to be provided by an OON provider.  
 
You asked the Plan to pre-approve the vision services. You say that you have been seeing this provider for 
many years. The Plan denied your request. The Plan says there are network providers who can provide these 
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 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 
vision services to be provided by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on February 20, 
2023. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that you are requesting a 
reconsideration of the denied charges. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient mental 
health visit provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care (99222) provided on January 25, 
2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Review of the file shows the enrollee was registered outpatient hospital; 
therefore, it would be inappropriate to report Current Procedural Terminology (CPT) 99222 in inpatient place 
of service 21. We looked at 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 pay 
for inpatient hospital care (99222) provided on January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs device (33289). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the device 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 enrollees 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMs device (33289).