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

 
We decided that the Plan does not have to pre-approve a bone density scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is reasonable once every two years. 
 
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 scan. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee last had a full body dual-energy x-ray absorptiometry (DEXA) on August 25, 2021, 
which means the enrollee will be eligible again on August 25, 2023.  
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a bone density scan.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zarxio. 
 You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the case file does 
not contain documentation of trial and failure of Neupogen and Nivestym. The documentation does not support 
that Neupogen and Nivestym would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. 
 
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 Zarxio.
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 the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements were not 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires 
a  trial of an injectable biphosphonate before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drug. There is no documentation provided indicating that the plans required 
drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Evenity.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, 
unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, 
when performed (37221).  
 
You asked the Plan to pre-approve revascularization of the right iliac artery. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says that the site of the blockage must be more 
than 50 percent. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when the criteria in the rules 
section of this letter 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 revascularization of the right iliac 
artery. Our reviewer says that the enrollee meets coverage criteria and documentation supports the medical 
necessity of the procedures in question. Our physician reviewer found that the enrollee has known left iliac 
occlusion with diminished ankle-brachial index (ABI)s and less than one block claudication. The enrollee has 
been managed conservatively for over two years. And is being considered for a right to left femoral-femoral 
bypass but requires angiography prior to this for surgery planning and, if needed, optimization of right inflow 
iliac arteries as both legs will be dependent on the right iliac inflow once the femoral-femoral bypass is 
complete. The requested procedure is 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 revascularization of the right iliac artery have been met. Therefore, we decided 
that the Plan has to pre-approve revascularization, endovascular, open or percutaneous, iliac artery, unilateral, 
initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 
performed (37221).    
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 LTACH is medically necessary. The 
Plan denied your request. The Plan says that LTACH 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. 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. The Plan has 
approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the request for approval of admission to a SNF 
does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from January 15, 2023, 
to January 16, 2023, and from January 25, 2023, to January 27, 2023. 
 
You asked the Plan to pay for the medication. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the self-administered drugs you received during your 
outpatient hospital stays are 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 pay for the self-administered drugs 
provided from January 15, 2023, to January 16, 2023, and from January 25, 2023, to January 27, 2023.  
 
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. 
 
Your complaint about not having received these self-administered drugs is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
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 you are requesting an expedited 
reconsideration stating the enrollee meets and/or exceeds the requirements for an LTACH level of care. The 
Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in 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 where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to the SNF is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 a home ventilator. You say that the patient needs a home ventilator because 
target tidal volumes cannot be reached with a BiLevel positive airway pressure (BiPAP) device. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary because a BiPAP with average 
volume-assured pressure support (AVAPS) will meet the patient's needs. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is a 59-year-old 
female with a history of asthma, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea 
syndrome (OSAS). She is not using a home positive airway pressure (PAP) device. The submitted pulmonary 
evaluation includes arterial blood gas analysis (ABG) showing hypercarbia (pH 7.41, PaCO2 70, and PaO2 60). 
Complete pulmonary function testing (PFT) results are described as a reduced FEV-1, normal FEV-1/FVC, 
normal lung volumes and normal DLCO. The member was recently admitted to acute care for heart failure and 
improved with appropriate therapies. A request is now made for a home mechanical ventilator with PSV (TgV) 
mode with Auto-EPAP (AE) to assure adequate tidal volume ventilation. The addition of volume assurance 
may benefit this member and the need for positive pressure ventilation is not disputed. However, providers did 
not submit a compelling rationale that supports use of a home mechanical ventilator (HMV) to deliver this 
assistance rather than a BiPAP with a backup rate and AVAPS. The member does not appear to have the 
severity of illness that would justify the need for a home mechanical ventilator (HMV). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vasectomy (55250). 
 
You asked the Plan to pre-approve a vasectomy . 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. Medicare rules say that elective hysterectomy, tubal ligation, and 
vasectomy, if the primary indication for these procedures is sterilization. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a vasectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
vasectomy (55250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated (36478). 
 
You asked the Plan to pre-approve endovenous ablation therapy. 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 follows Medicare rules. Medicare rules say that in contrast to ERFA and laser procedures, intra-
operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of 
sclerotherapy for varicose veins, therefore, intra-operative ultrasound guidance will not be separately covered 
for sclerotherapy. 
 
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 endovenous ablation therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not meet coverage criteria and does not support the medical necessity of the procedure in question. 
Coverage criteria require that the enrollee's symptoms be attributable to the varicose veins and are significant 
enough to impair mobility.  Additionally, there needs to be evidence of absence of deep vein thrombosis (DVT) 
and the presence of significant reflux in the vein to be treated. There needs to be a demonstration that the 
patient failed conservative efforts. As the documentation does not document any of these elements, coverage 
criteria have not been met and there is no evidence that the procedure is medically necessary. Additionally, it 
appears that the plan for ablation was made prior to obtaining results of the venous duplex examination.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all 
imaging guidance and monitoring, percutaneous, laser; first vein treated (36478).
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 are appealing this denial. The Plan denied your 
request. The Plan says medical necessity for an IRF admission has not been met.  
 
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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met with another device. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable and necessary.  Our physician reviewer found the records document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode, which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.