Persius/hicric huggingface dataset:
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 would greatly benefit from 
LTACH services. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
LTACH services. 
 
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 does not require services that they are not currently receiving at the 
setting provided by the health Plan. The elements of the coverage rules are not satisfied, and 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 has endured a complex 
hospitalization and needs continued acute care to prevent further complications and possible readmission to the 
short term acute care hospital. You also say the enrollee is still too medically complex for a lower level of care.  
The Plan denied your request. The Plan says the enrollee can safely receive the care they need in a hospital 
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 there is concern that the enrollee's left-sided pigtail catheter has minimal drainage and may be clogged. This must be addressed before it is safe to consider transfer. 
 
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 long term acute care hospital LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission 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 does not require services at the LTACH that are not available at the acute 
care hospital. 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 Plan. Given there are offered alternatives, LTACH services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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's condition requires an 
LTACH admission. 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 appears to be unstable and requires additional acute care services that can 
safely be provided at the current facility until more stable and appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to 
the LTACH is not medically necessary as it would not be clinically advantageous at this time. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT to be provided by an OON provider.  
 
You asked the Plan to pre-approve OON PT. You say that there are no providers in your area that take your 
insurance. The Plan denied your request. The Plan says in-network providers are available. 
 
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 
PT to be provided by an OON provider.
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 requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug does not meet the step-therapy requirements for 
approval. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
requested drug does not meet the necessary criteria for approval. Our physician reviewer found the Plan 
requires a trial of Forteo before they will approve the requested drug. 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. 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
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 is in need of inpatient rehabilitation 
facility admission. The Plan denied your request. The Plan says the enrollee's records do not show complex 
rehabilitation needs that require frequent evaluation by a rehabilitation physician. The Plan says services may 
be provided at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
records support 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. It is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jemperli. 
 
You asked the Plan to pre-approve Jemperli. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 Jemperli. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for review. 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 Jemperli have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Jemperli.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit (J0885). 
 
You asked the Plan to pre-approve Procrit. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the requested use of this drug is not a medically accepted indication. 
 
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 Procrit. Our reviewer says that the 
requested use of Procrit is not medically necessary. Our physician reviewer found the record provided does not 
indicate that the enrollee requires blood transfusion. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. Therefore, the reviewer found that the 
requested use of Procrit 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit (J0885).
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF 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 has no active comorbidities and does not require continued inpatient 
hospitalization during rehabilitation for close medical motoring.  
 
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 an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve the requested services. You say that you do not want to have another stroke. 
The Plan denied your request. The Plan says the requested services are not reasonable and necessary.  
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that you have no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted 
on ECG monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation 
with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was not 
superior to usual care in reducing stroke or systemic embolism among those at high risk of stroke but without a 
known prior history of atrial fibrillation. At this time, insertion of an ILR would not be considered medically 
appropriate and necessary in your 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve the requested device. You say that the device is needed to help manage 
respiratory needs. The Plan denied your request. The Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
 We looked at the file and the rules. The record does not show that the enrollee has cystic fibrosis, 
bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical 
condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve injection. 
 
You asked the Plan to pre-approve genicular nerve injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because based on the medical 
literature this procedure is considered experimental or investigational and has not been proven to be beneficial 
for your condition. 
 
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 genicular nerve injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered investigational/ experimental therapy. It is the subject of ongoing 
clinical trials.  Therefore, the request is deemed not medically reasonable and 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 genicular nerve injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve injection.
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 these services are medically necessary. The Plan 
denied your request. The Plan says the services you need can be provided safely in other settings.  
 
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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office or other outpatient consultation denoted by 
procedure code 99244. 
 
You asked the Plan to pre-approve an office or other outpatient consultation. You say that the requested service 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99244 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99244 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of an office or other outpatient consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve an office or other outpatient consultation denoted by procedure code 
99244.