Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 You asked the Plan to pre-approve Truxima. 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. 
 
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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
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 is able to get proper 
treatment at the facility. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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: 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 after your hip fracture your need rehabilitation so 
you can regain maximum function. 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 your 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: 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 daily doctor oversight and daily 
nursing management for medications. The Plan denied your request. The Plan says the IRF services you are 
requesting 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. 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. 
 
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 computer-assisted surgical navigation MAKOplasty. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested computer assistance is 
not needed for the approved reverse shoulder arthroplasty. The outcomes are not proven to be better than 
conventional open surgery. The computer-assisted surgical navigation is 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 computer-assisted surgical navigation MAKOplasty.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation (A0100). 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary.  The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 40 one-way 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 routine transportation (A0100).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 You asked the Plan to pre-approve Genvisc. You say that this treatment will allow the enrollee to improve their 
daily quality of life regarding their mobility. The Plan denied your request. The Plan says the enrollee does not 
have any stated contraindications to the preferred products, and has not tried any of the preferred agents. The 
Plan also says the provider does not provide a rationale for use of the non-preferred product for safety or 
efficacy. 
 
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 Genvisc. Our reviewer says that the 
enrollee does not meet the coverage criteria for Genvisc. Our physician reviewer found the Plan requires a trial 
of Monovisc, Orthovisc, Synvisc or Synvisc One before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. Our reviewer also found that there is no documentation 
provided indicating that the Plans required drugs 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal surgery and arthrodesis. 
 
You asked the Plan to pre-approve spinal surgery and arthrodesis. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the requested services are not medically necesary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 spinal surgery and arthrodesis. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a large lumbar facet cyst. Excision of this large cyst will create 
lumbar instability. Fusion at this one level is needed. Therefore, the enrollee does meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery and arthrodesis have been met. Therefore, we decided that the 
Plan has to pre-approve spinal surgery and arthrodesis.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided intensity-modulated radiation therapy 
(IG-IMRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that IMRT for bone or lung metastases is uncommonly needed for palliative treatment. For this case, 
while there are planning records, there is no dosimetric rationale for IMRT or explanation for why IMRT 
would be needed over 2D or 3D radiation. IMRT can be considered medically necessary (even for palliation and/or non-standard indications) when justified by quantitative dose measures- when the dose-volume exposure 
of critical structures in unacceptable without IMRT.  For this case, the volume is somewhat more complex than 
a case where just the spine or rib would be treated such that 3D radiation is plausibly needed over 2D radiation. 
However, the need for IMRT is not justified based upon quantifiable dosimetric measures or a plausible 
rationale. IMRT would not be furnished in accordance with accepted standards of medical practice. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve image-guided intensity-modulated radiation therapy (IG-IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of permanent cardiac 
contractility modulation system, including contractility evaluation when performed, and programming of 
sensing and therapeutic parameters; pulse generator with transvenous electrodes (0408T). 
 
You asked the Plan to pre-approve an optimizer device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that 
this service is considered experimental and investigational because it is not identified as widely used and 
generally accepted as reported in nationally recognized peer-reviewed medical literature published in the 
English language. 
 
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 an Optimizer device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an exhaustive review of the current medical literature pertaining to the CCM system 
confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical 
trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple 
studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional 
capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, the CCM system is not medically necessary for you. 
 
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 Optimizer device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an insertion or replacement of permanent cardiac contractility modulation system, 
including contractility evaluation when performed, and programming of sensing and therapeutic parameters; 
pulse generator with transvenous electrodes (0408T).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation. 
 
You asked the Plan to pre-approve non-emergency transportation. You say that the enrollee needs 
transportation assistance because they require dialysis, a lifesaving treatment, three times each week to 
maintain their health. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for 
treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, 
sensing lead, implantable pulse generator). 
 
You asked the Plan to pre-approve insertion or replacement of neurostimulator system. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 insertion or replacement of 
neurostimulator system. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has attempted and failed conventional treatment including continuous positive airway pressure (CPAP)/mask desensitization and bilevel 
positive airway pressure (BiPAP). Symptoms persist that interfere with his safety, wellbeing, and quality of 
life. The records from the provider show that the enrollee complains of chronic fatigue and lack of energy, 
excess daytime sleepiness, and memory and concentration problems. The notes show the enrollee is being 
treated with Adaptive Servo-Ventilation (ASV). The notes show poor compliance with usage of ASV with 
average daily usage of 31 minutes. The notes also say that the ASV device is therapeutic and beneficial for the 
enrollee when used. The provider has ordered a memory foam addition to the mask. The enrollee has chronic 
ventilator dependence due to central alveolar hypoventilation. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of neurostimulator system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator 
system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation 
lead, sensing lead, implantable pulse generator).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen (J0885). 
 You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Epogen. Our reviewer says that the 
enrollee does not meet the coverage criteria for Epogen. Our physician reviewer found the Plan requires a trial 
of Retacrit or Procrit before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drugs. Our reviewer also found that there is no documentation provided indicating that the 
Plans required drugs 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 Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen (J0885).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar laminectomy (63030) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a lumbar laminectomy. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 
a lumbar laminectomy (63030) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the wound is not Wagner grade 3 or higher. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered for 
diabetic wounds of the lower extremities in patients who meet specific criteria. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical documentation does not support that the enrollee is suffering with a Wagner grade 3 
ulceration. There is no evidence of tunneling, exposed deep soft tissue, or osteomyelitis. The ulceration does 
not meet the recommended criteria.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy.