Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support the need for 
the LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and is currently unstable for transfer to an LTACH. 
 
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 was admitted with a small bowel obstruction and required operative 
intervention. The record indicates that the enrollee has ongoing acute medical issues and still requires acute 
care services. The enrollee continues to receive acute care services and these have not been denied.  The medical record does not indicate that the enrollee requires services that are not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 has no mobility and needs a 
high level of care due to their bed sores and heart failure. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee can safely receive the care they need in another 
setting.  
 
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 the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that peer-reviewed literature clearly supports this request. 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes without facet 
degenerative joint disorder or foraminal stenosis. The cause of the enrollee's back pain is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an 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 enrollee does not meet Medicare guidelines for 
services in 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that they would meet criteria for admission to an IRF. There is no indication that the enrollee 
would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain their functional status.  The 
member can receive further services 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is a medical necessity. The 
Plan denied your request. The Plan says according to the information reviewed on appeal, the requested service 
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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that are not currently receiving but that would be available at the LTACH facility. The elements of the 
coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wheelchair provided on January 24, 
2023, to February 24, 2023. 
 
You asked the Plan to waive the coinsurance for the wheelchair. You say that you thought you owned this 
wheelchair and were told it was being taken care of. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the wheelchair. This item/service falls within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You are being asked to pay $6.46 each month, which is 20% coinsurance of 
the allowed amount for the wheelchair ($32.31 allowed amount x 20% coinsurance = $6.46). Therefore, we 
decided that the Plan does not have to waive the coinsurance for the wheelchair provided on January 24, 2023, 
to February 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve the drug. You say that that it is critical for the enrollee to have Imfinzi. The 
Plan denied your request. The Plan says Imfinzi is not medically necessary.  
 
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 the drug. Our reviewer says that Imfinzi 
is not medically necessary. Our physician reviewer found that the requested use of Imfinzi is not FDA-
approved and there are no documented images after completion of chemoradiation. Also, Imfinzi is not 
supported by one of the major drug compendia or by clinical research. 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Imfinzi.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you need a second oxygen 
concentrator so that you have one on each floor of your house. The Plan denied your request. The Plan says the 
requested second/duplicate oxygen concentrator would be a convenience item and not covered by Medicare or 
the members Health Plan benefits. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an oxygen concentrator that is meeting your needs. This serves the same purpose 
as an oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a second oxygen 
concentrator (E1390).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Myobloc. 
 You asked the Plan to pre-approve Myobloc. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Xeomin before it will approve Myobloc. 
 
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 Myobloc. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Myobloc. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Xeomin. The record does not show that this would 
likely be less effective and/or 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 Myobloc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Myobloc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pregabalin. 
 
You asked the Plan to pre-approve Pregabalin. You say that the services are medically necessary. 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 Pregabalin.  Benefits for Pregabalin 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). The home ventilator is being 
requested for use in intelligent volume assured pressure support (IVAPS) mode with auto-EPAP (AE) which 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Medicare does not cover a ventilator for this use. 
 
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 a home ventilator.
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 disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested admission 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 the enrollee required supervision to contact guard assistance for transfers and 
ambulation. The enrollee is at or near a home care level and does not require intensive rehabilitation services. 
Therefore, the enrollee does not meet criteria for the requested admission. 
 
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 placement of implantable loop recorder (ILR) device 
(33285). 
 
You asked the Plan to pre-approve an ILR. You say that an ILR is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says an ILR 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 an ILR. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve placement of implantable loop recorder (ILR) device (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery services (22558, 22845, 22853, 20930). 
 
You asked the Plan to pre-approve spinal surgery services. You say that the requested spinal surgery is a 
necessity for your care. The Plan denied your request. The Plan says the requested spinal surgery 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 spinal surgery services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no imaging studies provided showing spinal instability. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal surgery services (22558, 22845, 22853, 20930).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 You asked the Plan to pre-approve Lupron Depot. 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 Lupron Depot. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found 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. The requested service cannot be 
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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.