Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a contact layer dressing (Adaptic One Touch) (A6207), 
270 units. 
 
You asked the Plan to pre-approve the supplies. You say that your wound is leaking quite a lot which requires 
it be changed daily. You say that you have had several bacterial infections due to the leakage. You also say that 
you have been purchasing these on your own which has become a financial burden. The Plan denied your 
request. The Plan says the requested supplies are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the supplies. Our reviewer says that the 
requested supplies are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not support that the requested dressing is being used with a non-
adherent or semi-adherent layer as part of the dressing. Although it is reasonable to continue using Adaptic One 
Touch as part of the wound care, it is not medically reasonable or necessary for the enrollee's dressing to be 
changed daily. 
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a contact layer dressing (Adaptic One Touch) (A6207), 270 units.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
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 is medially stable. While the enrollee would benefit from physical and 
occupational therapy the enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such as in a skilled nursing facility or in a behavioral unit with therapies as needed.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not 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. Medically necessary care can 
be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab (Rituxan). 
 You asked the Plan to pre-approve Rituxan. You say that the requested drug is necessary to better control the 
enrollee's aggressive condition. The Plan denied your request. The Plan says the enrollee has not tried and 
failed the preferred drugs, Ruxience or Truxima. 
 
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 Rituxan. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
the enrollee has tried and failed the preferred drugs, Ruxience or Truxima. The reviewer also found that the 
record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the 
plan's preferred drugs. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituximab (Rituxan).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the 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 Prolia. Our reviewer says that that 
Prolia is not medically necessary Our physician reviewer found that the enrollee has not tried and failed the 
required drug zoledronic acid. There is no documentation indicating that the Plan's required drug would likely 
be less effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. 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 TMS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the information provided, this enrollee does not meet the clinical criteria for the use of 
Transcranial Magnetic Stimulation (TMS) therapy utilizing MCG criteria B-801-T as she does not meet the 
criteria. She has had no additional trials of antidepressant medication which included 2 antidepressants from 2 
different classes and there is no documentation of augmentation therefore, making the procedure not reasonable or 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 TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Transcranial Magnetic Stimulation (TMS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too medically complex for 
a lower level of care. You say that the enrollee is not a candidate for inpatient rehabilitation as they are unable 
to tolerate 3 hours of therapy daily. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in the current 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 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: 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 admission to an LTACH is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee 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 is receiving appropriate care at the present acute care hospital. 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. 
 
  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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (A0110) to a non-plan 
approved provider. 
 
  You asked the Plan to pre-approve non-emergency transportation. You say that you do not have a car nor do 
you have anyone to drive you that distance. You also say that you need to have teeth pulled, and there is not a 
closer dental provider in your area. The Plan denied your request. The Plan says there are dental providers 1.5 
miles within in your area. The Plan also say the location you have requested to be transported to is not a plan 
approved location.  
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trip is to a plan-approved location within the plan service 
area. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation (A0110) to a non-plan approved provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc (J7329). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the provider requested Trivisc for treatment of osteoarthritis of the right knee. The enrollee has not 
trialed one viscosupplemental treatment such as Synvisc/Synvisc-One or Euflexxa. Step therapy, as outlined by 
the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered. Without the support of the documentation, Trivisc is not 
approved as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trivisc (J7329).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection PCR panel (87798, 87481) provided on 
November 9, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says PCR testing is not indicated as the following are appropriate means to 
verify fungal infection: direct microscopic examination with potassium hydroxide, fungal culture of 
desquamated subungual material, or fungal stain of a nail clippings fixed in formalin.  
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the PCR testing for this enrollees anterior left leg skin and toenail was not medically 
reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the fungal infection PCR panel (87798, 87481) provided on November 9, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima (Q5115). 
 You asked the Plan to pre-approve Truxima. 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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima (Q5115).
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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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. 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 the enrollee is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the medical records to be 
reviewed and the authorization to be reconsidered and approved. The Plan denied your request. The Plan says 
the records show that the device is going to be used only in a CPAP/Bi-level PAP mode. Additionally, the 
records do not show that the enrollee has failed treatment with a BiPAP or CPAP device, or that he has had 
abnormal arterial blood gases outside of the hospital or an abnormal sleep oximetry test. 
 
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 the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of such a 
device has not been documented. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 were under the impression that the enrollee's 
skilled therapy would continue until they reached their full potential. The Plan denied your request. The Plan 
says there is not an expectation that the enrollee would achieve full improvement in a reasonable duration of 
time. 
 
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 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 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.