Persius/hicric huggingface dataset:
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 are requesting reconsideration of denied 
authorization The Plan denied your request. The Plan says the coverage criteria 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 the complexity of your nursing, medical, and rehabilitation needs do 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. Medically necessary care can be provided in a different level of care. There is 
no 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: 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 lives alone which is unsafe as they are at 
a high risk of falling. You say that an IRF is the recommended next level of care for continued medical and 
pain management along with physical and occupational therapies. 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service May 4, 2022.  
 You asked the Plan to pay for procedure code 95861. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says the billed number of units are not supported by the 
records as both provided and medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
We asked our coder 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 95861. Our reviewer found that the 
documentation submitted does not meet criteria. Regardless of the number of levels studied or whether the 
study was unilateral or bilateral, only one unit of this code is supported.  
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95861 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 95861 billed for date of service May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a right hip orthosis with additional stabilization (L1686, 
L2624) rendered on June 23, 2023. 
 You asked the Plan to pay for the item. You say that this is medically necessary. The Plan denied your request. 
The Plan says this 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 pay for the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no clear documentation available for review that supports the enrollee has significant hip 
pain or any abnormal physical findings that would necessitate treatment with an orthosis. The requested 
orthosis does not appear appropriate to the patients medical needs and condition. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pay for a right hip orthosis with additional stabilization (L1686, L2624) rendered on June 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan injections (J7323). 
 
You asked the Plan to pre-approve Hyaluronan injections. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the 
patient has failed at least three months of conservative therapy. 
 
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 Hyaluronan injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the records do not show three 
months of conservative therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyaluronan injections (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced knee, rotational unit and advanced pylon 
features for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve an advanced knee, rotational unit and advanced pylon. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items 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 an advanced knee, rotational unit, and 
advanced pylon. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee 
needs a shock-reducing pylon. The treating physician's progress notes do not support that the enrollee requires 
a Ossur Power Knee which exceeds the enrollee's medical needs, or that the enrollee requires a heavier 
microprocessor knee over a mechanical knee. This request exceeds the enrollee's medical and functional needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced knee, rotational unit, and advanced pylon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an advanced knee, rotational unit and 
advanced pylon features for a lower-limb prosthesis.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Eylea injections. 
 You asked the Plan to pre-approve the medication. You say that the enrollee has tried Avastin and need the use 
of Eylea. The Plan denied your request. The Plan says the enrollee has not tried the prior injection Avastin to 
be approved for Eylea. 
 
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 reviewer says that 
the enrollee does not need Eylea. Our physician reviewer found the enrollee used Avastin, but there is no clear 
indication that the enrollee has failed the Avastin therapy. There is no indication that the Plan's 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Eylea injections.  
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white cane. 
 
You asked the Plan to pre-approve the cane. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only durable medical equipment that makes a 
meaningful contribution in the treatment of an illness or injury is covered. 
 
Medicare does not consider a white cane to be covered durable medical equipment at this time, as it is more an 
identifying and self-help device rather than an item which makes a meaningful contribution in the treatment of 
an illness or injury. Based on this information, we decided that Medicare rules for coverage of the cane have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a white cane.
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 the requested SNF services are medically necessary. The Plan denied your request. The Plan says 
the enrollee does not meet Medicare guidelines for services in a SNF.  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: 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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs a doctor to monitor their care at least three days per week or need a medical team to manage the 
health care decisions.  
 
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 enrollee 
was admitted for  surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. 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 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: 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 has tried and failed alendronate from 2021 through 2022. The Plan denied your request. The Plan says Prolia is subject to Step Therapy. For the requested drug to be covered, the enrollee must have 
tried and failed treatment with one intravenous bisphosphonate therapy (such as zoledronic acid).  
 
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 the 
requested drug is not medically necessary. Our physician reviewer found the Plan requires a trial of one 
intravenous bisphosphonate therapy (such as zoledronic acid) before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drug(s). There is no documentation indicating that 
the Plan's required drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca (Q5111). 
 You asked the Plan to pre-approve Udenyca. You say that this drug is necessary and has already been approved 
by the enrollee's other health plan. The Plan denied your request. The Plan says the enrollee must try and fail 
one of the Plan's preferred alternatives: Neulasta or Fulphila. 
 
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 Udenyca. Our reviewer says that the 
Plans step therapy criteria have not been met. Our physician reviewer found that the Plan requires a trial of 
Neulasta of Fulphila before they will approve the requested drug. In this case, the patient has not tried and 
failed either of the required drugs. There is no documentation indicating that the plan's 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the molecular pathology procedure, Level 5 (81404 x2) 
and CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene 
sequence (81223).  
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the Plan considers genetic 
testing for hereditary pancreatitis experimental and investigational for all other indications.  
 
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 genetic testing. 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 being referred for hereditary pancreatitis genetic testing. The testing requested is investigational and 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the molecular pathology procedure, Level 5 (81404 x2) and CFTR (cystic fibrosis 
transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence (81223).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of lower extremities (37225, 37229). 
 
You asked the Plan to pre-approve the revascularization procedure. You say that the enrollee has had an 
inadequate response to conservative medical therapy. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the revascularization procedure. Our 
reviewer says that the requested revascularization procedure is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates the enrollee has 
normal ankle brachial index (ABI) whose symptoms improve with walking. There is no sign of limb threat. A 
pulse examination is not documented. Tibial intervention in the absence of limb threat has a high risk of doing more harm than good. Therefore, the reviewer found that the requested revascularization procedure 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 the revascularization procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve revascularization of lower extremities (37225, 37229).