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

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have 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 the medication. Our reviewer says that 
the criteria for coverage of Prolia have not been met. Our physician reviewer found that the Plan requires a trial 
of bisphosphonate, pamidronate and zoledronic acid and methylprednisolone before they will approve Prolia. 
In this case, the enrollee has not tried and failed all the required drugs specifically bisphosphonate therapy. 
There is no documentation provided indicating that the Plan's required drugs would likely be less effective 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.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says there is no 
documentation that indicated the enrollee's Avastin injections have failed or are contraindicated. 
 
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 Eylea. Our reviewer says that the 
patient does not meet the coverage criteria. Our physician reviewer found the Plan requires a trial of Avastin 
before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. 
Our reviewer also found that there is no documentation provided indicating that the Plan's required drug would 
likely be less effective and/or likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the requirements have 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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is noted to have lower extremity lymphedema. The documentation indicates that the 
enrollee has tried conservative measures, including compression stockings and elevation and continues to 
experience lymphedema of the lower extremities. The clinical documentation dated 4/4/2023 indicates that the 
enrollee has physical examination findings of lower extremity edema. There is a lack of documentation 
indicating truncal edema and there are no objective measurements indicating that the enrollee has failed 
treatment with a standard pneumatic compression device. 
 
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 a pneumatic compression device (E0652, E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qvar Redihaler. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee needs this medication. 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 Qvar Redihaler.   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Left Atrial Appendage Closure (LAAC). 
 
You asked the Plan to pre-approve Percutaneous LAAC. You say that the requested LAAC is medically 
necessary.  The Plan denied your request. The Plan says the requested LAAC 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 LAAC. Our reviewer says that the 
requested LAAC is not medically necessary.  Our physician reviewer found the enrollee is with history of atrial 
fibrillation for which there is no documentation of inability to take anticoagulation. As such, guidelines would 
not support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered 
reasonable or medically necessary in this enrollee's 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 LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Percutaneous Left Atrial Appendage Closure (LAAC).
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 admitting the enrollee in a lower level of 
care to IRF admission will result in the enrollee back pedaling in their health status. The Plan denied your 
request. The Plan says the enrollee does not meet criteria. The Plan also says that admission is not medically 
necessary and skilled nursing facility level of care was recommended.  
 
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 does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that are not already available 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. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve Leqembi. You say that the enrollee has a diagnosis of early mild 
Alzheimer's dementia. You say that though the MOCA testing demonstrates significant impairment, upon 
comprehensive clinical evaluation, the enrollee is high functioning and does not fulfill the criteria for advanced 
or 
severe dementia. You also say that denying or delaying the enrollee's treatment may cause further deterioration 
of their disease. The Plan denied your request. The Plan says the enrollee is not enrolled in a trial or registry. 
The Plan also says the enrollee has advanced end stage Alzheimer's disease and is unlikely to benefit from the 
therapy. 
 
The Plan follows Medicare rules. Medicare rules say that covers Food and Drug Administration (FDA) 
approved monoclonal antibodies directed against amyloid for the treatment of Alzheimers disease (AD) when 
furnished in accordance with coverage with evidence development (CED) for patients who have a clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia. 
 
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 Leqembi. Our reviewer says that the 
request for Leqembi is not medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has Alzheimer's disease with advanced dementia as documented by cognitive testing. 
Therefore, the reviewer found that the request for Leqembi is 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 Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi (J0174).  
 
Please note, the enrollee must be in the CED study in order for payment to be made for the services. Evidence 
of enrollment in a CED study may be requested by the Plan after the claim is submitted.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker, folding, wheeled, adjustable or fixed height 
(E0143) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a folding wheeled walker. You say that the enrollee needs the walker for 
surgery. The Plan denied your request. The Plan says the enrollee must use network providers to get her 
medical care and 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 
a walker, folding, wheeled, adjustable or fixed height (E0143) to be provided by an out-of-network (OON) 
provider.
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 IRF admission is needed to get stronger to go 
home. The Plan denied your request. The Plan says you do not meet the criteria for 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. You do not require treatment by multiple therapies. 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 
you would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 
in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 a delay in treatment could jeopardize the enrollee's 
ability to return home at a safe functional level. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for an IRF program.  
 
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 require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to be able to currently tolerate fifteen hours per week of 
rehabilitative services with regular physician evaluation.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair, percutaneous 
approach, including transseptal puncture when performed; initial prosthesis (33418) and an associated inpatient 
admission. 
 
You asked the Plan to pre-approve a transcatheter mitral valve replacement (TMVR). You say that the enrollee 
currently notes symptoms of decreased functional capacity and dyspnea with exertion. The Plan denied your 
request. The Plan says the request is not medically necessary because the records show the enrollee has 
degenerative (primary) mitral regurgitation and he does not have documentation of an independent evaluation 
and face-to-face visit with a heart team cardiac surgeon. 
 
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 transcatheter mitral valve replacement 
(TMVR). 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 not been independently evaluated by a 
cardiac surgeon. As such, the documentation is inadequate to confirm fulfillment of published CMS guidelines 
for TMVR. As a result, at this time TMVR would not be considered medically reasonable and necessary in this 
enrollee's 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 a transcatheter mitral valve replacement (TMVR) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve transcatheter mitral valve repair, percutaneous approach, 
including transseptal puncture when performed; initial prosthesis (33418) and an associated inpatient 
admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (22514). 
 
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 a percutaneous vertebral augmentation 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 detailed documentation is not evident regarding the worsening of pain. Additionally, there is no 
documentation of a progression of the body height loss, greater than 25 percent vertebral kyphotic deformity, 
or a severe impact on daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of 
retropulsion and other plausible causes of pain. Therefore, the enrollee does not meet LCD coverage 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous vertebral augmentation (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve continued care with an OON provider. You say that the continued care with 
the OON provider is medically necessary. The Plan denied your request. The Plan says the continued care with 
the OON provider is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued care with an OON provider. 
Our reviewer says that the continued care with the OON provider is not medically necessary. Our physician 
reviewer found there are credentialed, experienced physicians within the enrollees network who could be 
utilized for the enrollee's clinical condition. In summary, there is insufficient documentation to support the 
medical necessity for referral to an out-of-network provider for the enrollees office visit. 
 
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 care with an OON provider have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued care with an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and 
injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or 
CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484). 
 
You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 injections. Our physician reviewer 
found there is no documentation that the member has had at least 50 percent of sustained improvement in pain 
relief and/or improvement in function measured from baseline using SAME scale for at least 3 months. In 
addition, the provider is requesting repeat TFESIs bilaterally at the same level, by the same transforaminal 
approach, and there is no documentation that a different medication will be utilized for the repeat injection. The 
review has determined that the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional 
level (List separately in addition to code for primary procedure) (64484).