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

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request is not medically necessary because the records do not show the enrollee has 
had a formal, shared decision-making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
   
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 
service is not medically necessary. Our physician reviewer found while there is reference to consideration of 
the LAAC, there is no documentation of performance of an evidence-based shared decision-making interaction 
on anticoagulation. As such, guidelines would not support implantation of a LAAC in this 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 LAAC have not been met. Specifically, there is no documentation of a shared 
decision-making interaction. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
transcatheter closure of the left atrial appendage with endocardial implant (LAAC) (33340).
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 the LTACH services. You say that the enrollee is stable and suitable for 
transfer to a LTACH. You say that the enrollee cannot be adequately care for in their current condition at a 
skilled nursing facility. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the 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 LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that the enrollee has been taking Fosamax since October 
2021. You also say that this has been ineffective. The Plan denied your request. The Plan says the enrollee has 
not tried and failed the preferred drugs, zoledronic acid or 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 Evenity. Our reviewer says that the step 
therapy criteria for Evenity have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has not tried and failed the preferred drugs, zoledronic acid or Prolia. The 
reviewer found that the record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the Plan's preferred drugs. Therefore, the reviewer found that the step therapy criteria 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that the enrollee has tried all conventional 
treatment options, and nothing has provided sustained pain relief. You say that this level of pain is causing the 
enrollee significant limitations in daily living, the ability to work, and the ability to maintain independence. The 
Plan denied your request. The Plan says that the sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
system is the subject of ongoing clinical trials and is considered experimental therapy. 
 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records show that the enrollee has had a previous spinal fusion at the 
intended level which is a contraindication for the procedure. 
 
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 Intracept procedure. 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 a fusion and radicular leg pain which is a contraindication to 
Intracept. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Intracept procedure (64628).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EYLEA. 
 You asked the Plan to pre-approve EYLEA. You say that Byooviz is not carried in the office so would like to 
use EYLEA. The Plan denied your request. The Plan says there is not a record from the prescriber that shows 
the enrollee has tried the preferred drug Byooviz and it hasn't worked, or that they have medical reasons that 
prevent them from using it. This preferred drug requires prior authorization. 
 
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 
service is not medically necessary. Our physician reviewer found the requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.   
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic Roux-en-Y gastric bypass (RYGBP) 
(43644). 
 
You asked the Plan to pre-approve RYGBP procedure. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that open and laparoscopic Roux-en-Y gastric bypass 
(RYGBP) is covered for Medicare beneficiaries who have a body-mass index greater than or equal to 35.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RYGBP procedure have not been met. Specifically, the file does not support that the enrollee has a 
body mass index (BMI) greater than or equal to 35. Therefore, we decided that the Plan does not have to pre-
approve a laparoscopic Roux-en-Y gastric bypass (RYGBP) (43644).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nasopharyngoscopy with dilation of eustachian tube 
(69705, 69706). 
 
You asked the Plan to pre-approve the outpatient service. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the records do not show that you have a type B or type C 
tympanogram. 
 
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 outpatient service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has sensorineural hearing loss and eustachian 
tube dysfunction in the setting of hypermobile tympanic membrane. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the 
reviewer found that the requested nasopharyngoscopy 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 the outpatient service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nasopharyngoscopy with dilation of eustachian tube (69705, 69706).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is truly the only solution for the 
enrollee's pain. The Plan denied your request. The Plan says this 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging (MRI) provided that shows only Modic 
changes without degenerative joint disease. The reviewer found that the documentation does not show a clear 
cause for the enrollee's pain. Therefore, the reviewer found that the requested Intracept procedure 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ILUMYA. 
 You asked the Plan to pre-approve ILUMYA. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not met the step therapy criteria. 
 
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 ILUMYA. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the requested medication is a new start. The 
provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 
The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from 
the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ILUMYA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ILUMYA.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy (PT) services to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve outpatient PT services. You say that you requested an expedited time frame 
due to the more than two months that have elapsed since the initial denial. The Plan denied your request. The 
Plan says the services can be provided in-network. 
 
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 
outpatient physical therapy (PT) services 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show  that the enrollee's care 
specifically requires the involvement of a doctor in the field of  Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee mush have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve 
self-care functioning.  
 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 and can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is 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, but the services required can be provided at a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary to treat the 
enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug does not meet the 
necessary requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the use of 
Opdivo is not FDA-approved for the enrollee's diagnosis due to being anaplastic lymphoma kinase (ALK) 
positive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
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 services are medically necessary as the hospital 
can only provide limited physical therapy and you require intensive rehab services. The Plan denied your 
request. The Plan says you do not meet the criteria for admission to an IRF.  
 
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 you do not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that it is getting hard to get up. The Plan 
denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer 
says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found you have some gait instability. Your strength is five out of five throughout. You are 
able to walk with a cane. The documentation does not support that you have arthritis noted in the record nor do 
you have complete inability to rise from a chair. Therefore, you do not meet criteria for the requested item. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 20, 2023, to 
August 11, 2023.  
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does 
not have documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing 
services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 20, 2023, to August 11, 2023.