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 it is not safe for the member to leave the 
hospital because swallow studies are pending, and they may need a permanent feeding tube. The Plan denied 
your request. The Plan says when the enrollee is ready to leave the hospital, they can receive this care in 
another setting, the request 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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 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 LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 provided documentation 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 she is 
not currently receiving but that would be available at the LTACH facility. The elements of coverage rules are not satisfied. The requested services 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF services to regain her 
maximum function. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided at a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 this 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 in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve outpatient office visit. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the Plan suggested the enrollee to meet a regular 
provider. 
 
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 health plan must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. 
 
The provider at issue in this case is not a network provider with the Plan. 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 outpatient office visit. Our reviewer says that the service is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has Parkinson's disease and a 
visit with a tertiary network provider is requested. The record provided indicates that the available care is 
available and adequate to meet the enrollee's medical needs the record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 outpatient office visit have not been met.  
 
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 outpatient office visit. Therefore, we decided that the 
Plan does not have to pre-approve an outpatient office visit to be provided by an out-of-network (OON) 
provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea HD. 
 You asked the Plan to pre-approve Eylea HD. You say that the enrollee is currently failing Eylea with 
increased and persistent edema. The Plan denied your request. The Plan says according to the information 
submitted, the enrollee has met some of the criteria, but there was no adequate medical justification as to why 
Eylea cannot be used. 
 
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 HD . Our reviewer says that the 
enrollee does not meet the criteria for Eylea HD. Our physician reviewer found the provided records are 
insufficient to indicate that the enrollee has tried and failed the plan's preferred step one alternative, nor does 
the enrollee show a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. Our physician reviewer also found 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 HD  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Eylea HD.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arcalyst. 
 
You asked the Plan to pre-approve Arcalyst. You say that the enrollee needs for treatment of pericarditis to 
prevent surgery. 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 Arcalyst. 
 
Benefits for Arcalyst 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has mild short-term memory loss and episode with loss of consciousness secondary to possible seizure. The 
record provided does not establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease 
and frontotemporal dementia or that the examination is being requested in the context of a clinical trial. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 meets IRF criteria, and a lower level of 
care in a skilled nursing facility cannot provide the total interdisciplinary team approach needed. You would 
like reconsideration based on the records submitted. The Plan denied your request. The Plan says admission to 
an IRF 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 complexity of the enrollee's nursing, medical, and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation 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: 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 is a medical necessity.  The 
Plan denied your request. The Plan says based on Medicare guidelines, 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 improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to 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 at this time as it would not be clinically advantageous.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections (SIJI) and procedures. 
 
You asked the Plan to pre-approve SIJI. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says a treatment plan that shows the procedure will be done at no more 
than two levels and will be between the C1-S1 levels of the spine. You should share a copy of this decision 
with your doctor so you and your doctor can discuss next steps. 
 The Plan follows Medicare rules. Medicare rules say that SIJI will be considered medically reasonable and 
necessary when all the following requirements 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 SIJI. Our reviewer says that the service 
is not medically necessary. Our physician reviewer found this is considered experimental therapy because of 
the wide variation in efficacy reported in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve sacroiliac joint injections (SIJI) and procedures.
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 want to go to an inpatient rehabilitation facility. 
The Plan denied your request. The Plan says your condition does not meet all the requirements for inpatient 
rehabilitation admission. 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 your 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panoramic imaging (D0330) and dental implant 
services. 
 
You asked the Plan to pre-approve the dental services. You say that all of these services are medically 
necessary. The Plan denied your request. The Plan says these services have been processed and denied 
correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0330 was exhausted on date of service October 13, 2023. The remaining dental services are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve panoramic 
imaging (D0330) and dental implant services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E0953, E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2323, E2359, E2377, E2620, 
E2624). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the existing chair can be 
repaired, but it would be more cost effective to purchase a new chair as the repairs on the current chair would 
be approximately $8,000.00. You also say that the current chair is nearly 5 years old and has no warranty left 
on it. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with a group 3 power wheelchair. The Plan also says the electronic connection, expandable 
controller harness, and expandable controller cannot be covered as it is not medically necessary to control the 
three requested power options through the joystick (drive interface). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found provided records from the prescribing physician do not support that the 
enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records 
from the prescribing physician do not document the need for the power tilt and recline for skin protection. 
Records do not document the enrollee performs bladder self-catheterization or that the enrollee has increased 
muscle tone or spasticity to meet criteria for the power tilt and recline and thus the multiple power option base. 
As the requested wheelchair base does not meet Medicare coverage criteria, the requested accessories are not 
covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0953, 
E0955, E0956, E1007, E1012, E1028, E2311, E2313, E2323, E2359, E2377, E2620, E2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee requires the injection to 
treat knee pain. The Plan denied your request. The Plan says the requested procedure does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is morbidly obese and has bilateral knee pain. Her medication trials have 
included Lidocaine patches, Diclofenac, Gabapentin, Tramadol and Methocarbamol. Physical therapy was 
ordered. This is considered 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).