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

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve the drug. You say that the injections have a positive effect and has been 
helping to prevent blood clots. The Plan denied your request. The Plan says Euflexxa is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found that the most recent knee 
viscosupplemental injections were on June 9, 2023, but the notes do not describe the effect of the injections. 
The requested use of Euflexxa is not FDA-approved. Euflexxa is also not supported by one of the major drug 
compendia or by clinical research.  
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 Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology testing with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve OON gastroenterology testing. You say that since having COVID-19, your 
symptoms have gotten worse. The Plan denied your request. The Plan says care is available in-network. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve gastroenterology testing with an out-of-network (OON) provider.
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 does meet the medical complexity 
needed for inpatient rehabilitation and will need frequent physician visits for management of medical 
comorbidities. The Plan denied your request. The Plan says based on the available information, admission to 
IRF is not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 pneumonia, anemia and a tibial 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. You asked the Plan to pre-
approve physical therapy visits. You say that the enrollee needs the services as soon as possible so there is no 
break in care. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that provided 
records do not include medical notes from the enrollees treating physician documenting an order or need for 
additional skilled therapy services. Provided records include a plan of care with the physician's name typed into 
the signature section, but documentation does not show an actual signature or electronic signature confirming 
the established plan of care as required by the Medicare Benefit Policy Manual.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the enrollee has a history of 
stroke with left upper extremity weakness and spasticity. You say the MyoPro Motion G device is medically 
necessary as it would assist the enrollee with movement of her left arm. The Plan denied your request. The Plan 
says the requested item 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 a MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the American Heart Association recommends the device as an adjunct to 
standard therapy, not as support for daily self-care. The device is not reliably effective more than a year post 
stroke, has not been shown to be effective in setting of increased tone and spasticity. No Ashworth score is 
provided for the enrollee. The device has not been shown to significantly impact bathing, dressing, toileting or 
eating. Per Social Security Administration (SSA) 1862 (a)1 (A), the device is not the standard of care and has 
not been shown to reliably impact self-care. It is not as or more effective than standard 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures. 
 
You asked the Plan to pre-approve sacroiliac joint injections and procedures. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SIJI will be considered medically reasonable and 
necessary when all the criteria 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 sacroiliac joint injections and 
procedures. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
radiofrequency ablation of the lateral sacral branches is not covered due to the wide variation in effectiveness 
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 sacroiliac joint injections and procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. You asked the Plan to pre-
approve home health services. You say that the requested skilled nursing services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records 
provided do not document that the enrollee is receiving services under a plan of care established and 
periodically reviewed by a physician or allowed practitioner as required by the Medicare Benefit Policy 
Manual, Chapter 7 - Home Health Services, Section 30. Additionally, no medical notes from the enrollee's 
treating physician are provided documenting an order or need for home health skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve patent foramen ovale (PFO) closure with intracardiac 
echocardiography (ICE) while outside of the Plan's service area. 
 
You asked the Plan to pre-approve PFO procedure with ICE. You say that the enrollee needs this procedure 
within the next 30 days to prevent further life-altering stroke. The Plan denied your request. The Plan says 
elective services are not covered outside of the Plan's service area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.   
 
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 PFO procedure with ICE. Our reviewer 
says that the enrollee does not meet criteria for this service. Our physician reviewer found the enrollee could 
have foreseen requiring these services prior to leaving the Plan's service area. It would be reasonable to delay 
the services until the enrollee returns to the Plan service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PFO procedure with ICE have not been met. Therefore, we decided that the 
Plan does not have to pre-approve patent foramen ovale (PFO) closure with intracardiac echocardiography 
(ICE) while outside of the Plan's service area.
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 based on Medicare guidelines, the 
IRF services requested do not meet the requirements for approval.  
 
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 colitis, atrial fibrillation, hypotension and bacteremia. 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: 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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says they will continue to cover medically necessary acute 
and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of 
care (such as a skilled nursing facility), or until the clinical circumstances change such that LTACH may be 
reconsidered. 
 
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 acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that 
are not available at the acute care hospital where they are currently receiving care. There are no required 
medical services identified that are available at the LTACH, that are not available at the current health care 
setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says it 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 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 this is considered experimental/ investigational therapy. It is the subject of ongoing 
clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra. 
 
You asked the Plan to pre-approve Actemra. You say that you are trying to get the drug approved under Part D 
not Part B Medicare. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 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 Actemra.  
 
Benefits for Actemra 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: 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 enrollee's family and provider both feel that in-
patient rehabilitation is going to be the best for the enrollee to get her strength and her balance up so that she 
does not fall and get hurt any more. The Plan denied your request. The Plan says admission to an IRF is not 
reasonable or 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 enrollees 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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biofeedback therapy. 
 
You asked the Plan to pre-approve biofeedback therapy. You say that it is medically necessary. The Plan 
denied your request. The Plan says you do 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 biofeedback therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation did not list you as having one of the approved conditions 
(voiding dysfunction, migraine, cancer pain, neck and jaw pain). Biofeedback is indicated for helping gain 
voluntary control over involuntary functions. This therapy is also not indicated for psychosomatic conditions 
such as insomnia related to anxiety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of biofeedback therapy. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve biofeedback therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the pulp vitality test 
(D0460) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford any expenses and you would 
like the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for the 
limited oral evaluation has already been exhausted. Also, the pulp vitality test is not covered by the Plan. 
 
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 the Plan paid for a limited oral evaluation (D0140) on June 7, 2023, and July 13, 2023; therefore, your 
benefit for the limited oral evaluation was exhausted on the date of service of July 13, 2023. The pulp vitality 
test is not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay for 
a limited oral evaluation (D0140) and the pulp vitality test (D0460) provided on August 10, 2023.