Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity revascularization. 
 
You asked the Plan to pre-approve revascularization. You say that this is necessary to possibly prevent 
amputation of the lower limb. The Plan denied your request. The Plan says that the enrollee does not meet their 
coverage criteria. 
 
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 revascularization. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that based on the medical records provided, there is no clear documentation that the 
revascularization procedures at issue in this case meet all Medicare criteria for medically reasonable and 
necessary for the enrollee.  No claudication is reported in the History of Present Illness or Review of Systems; physical examination 
reports normal lower extremity pulses. Records do not document trial and failure of all non-surgical 
interventions for management of peripheral arterial disease (including anti-hyperlipidemia medication and 
cilostazol or pentoxifylline). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve lower extremity revascularization.
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 requires an IRF admission and needs 
cannot be met in a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's condition 
does not meet the requirements 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed. 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. 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 follows Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds. 
 
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 heavy duty extra wide hospital bed. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you are noted to 
have limited mobility and require assistance with daily activities. You also are noted to have a coccygeal 
pressure wound requiring home health wound care. You may have limited bed mobility and require a fixed 
height hospital bed. However, you weigh 162 lbs and do not require a bariatric hospital bed. Therefore, the 
requested heavy duty extra wide hospital bed 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 a heavy duty extra wide hospital bed have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee's level of care cannot be 
maintained in a skilled nursing facility or at home. The Plan denied your request. The Plan says the enrollee 
does not meet the requirements for an LTACH admission. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at an LTACH that the enrollee requires, that are not 
available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
admission 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab). 
 You asked the Plan to pre-approve Prolia (denosumab). You say that the requested drug is medically necessary 
to treat the enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee does not meet the 
step-therapy requirements for approval. 
 
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 Prolia (denosumab). Our reviewer says 
that the requested drug does not meet the criteria necessary for approval. Our physician reviewer found the 
Plan requires a trial of an injectable bisphosphonate before they will approve the requested drug, Prolia. The 
documentation submitted does not show the enrollee has tried and failed the Plan's preferred drugs. The 
available clinical documentation does not sufficiently support that the preferred drugs would likely be less 
effective or 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 Prolia (denosumab) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prolia (denosumab).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient services for substance abuse. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs to detox from 
alcohol. The Plan denied your request. The Plan says that the services are not a covered benefit. 
 
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. 
 
We looked at the file and the rules. The Plan denied services based on guidelines for a state or local 
government hospital. We find that the facility where the services will be provided is not a government facility. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Therefore, we decided that the Plan has to pre-approve inpatient services for 
substance abuse.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection (ESI) (64483, 
64484). 
 
You asked the Plan to pre-approve a transforaminal ESI. You say that you are requesting reconsideration for 
the denial of the ESI. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that patients should be part of an active rehabilitation 
program, home exercise program or functional restoration program. 
 
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 transforaminal ESI. Our reviewer says 
that the criteria have not been met. Our physician reviewer found the documentation of the enrollee's history 
and examination reveals conflicting information supporting the diagnosis of lumbar radiculopathy requiring a 
right L1-3 transforaminal ESI. The rules state that the enrollee's history, physical examination, and concordant 
radiological image-based diagnostic testing must support one of the following: lumbar, cervical or thoracic 
radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte 
complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis; or post-
laminectomy syndrome or acute herpes zoster associated pain. There is no evidence that the enrollee is 
participating in an active rehabilitation program, home exercise program or functional restoration program. 
Given the conflicting history and physical and lack of participation in an active rehabilitation program, home 
exercise program or functional restoration program, the criteria for this transforaminal ESI per the Local 
Coverage Determination have not been met. 
 
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 transforaminal ESI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transforaminal epidural steroid injection (ESI) (64483, 64484).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hysterectomy. 
 
You asked the Plan to pre-approve a hysterectomy. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no reason for the hysterectomy and due to increased risk, it is not medically 
indicated. 
 
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 hysterectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it is not standard of care to perform a hysterectomy for the indication of contraception. You do 
not have medical indications for hysterectomy. 
 
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 hysterectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hysterectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain strength and endurance 
before returning home. The Plan denied your request. The Plan says medical records do not support the need 
for an IRF admission and, the enrollee needs can be provided at 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance and to pay for an amalgam 
(D2140), a resin-based composite (D2332), and sales tax (D9985), provided on June 28, 2023, to July 24, 2023. 
 
You asked the Plan to waive the deductible and coinsurance and to pay for the dental services. You say that 
you believe the Plan should pay for this. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $50 deductible and a 50% coinsurance which applies to dental 
services.  
 
The item or service you asked the Plan to waive the deductible and coinsurance and to pay for falls within the 
dental services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $50 deductible and a 50% coinsurance which applies to covered dental services. This cost sharing is a 
contractual obligation that had not been met at the time the dental services was received on June 28, 2023, to July 24, 2023. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance and 
to pay for an amalgam (D2140), a resin-based composite (D2332), and sales tax (D9985), provided on June 28, 
2023, to July 24, 2023.
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 an IRF admission is medically necessary to regain 
maximum function. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 patient 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (Denosumab) injection (J0897). 
 You asked the Plan to pre-approve the medication. You say that Prolia (J0897) is medically necessity for the 
enrollee's treatment for osteoporosis.  The Plan denied your request. The Plan says this request does not meet 
the Plan's step therapy coverage criteria for Prolia.  
 
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 medication. Our reviewer says that 
the medically necessary criteria for coverage has not been met. Our physician reviewer found the Plan requires 
a trial of drug zoledronic acid and, a history of osteoporosis-related fracture before they will approve the 
requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the Plans required drug(s) would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia (Denosumab) injection (J0897).
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 meets IRF criteria and is reasonably 
expected to participate in and benefit from 15 hrs of therapy a week and requires daily physician oversight to 
actively manage medical conditions and comorbidities to optimize recovery and avoid hospitalization. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided safely in other settings, for 
example, a skilled nursing facility (SNF) or at home with home health services if appropriate.  
 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.