Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ruxience. 
 You asked the Plan to pre-approve Ruxience. You say that the enrollee is already on maximum doses of 
mycophenolate and other traditional disease-modifying antirheumatic drugs (DMARDs) and due to a risk of 
pulmonary disease, the enrollee requires the use of Rituxan. The Plan denied your request. The Plan says the 
enrollee does not meet the step-therapy requirements necessary for approval. 
 
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 Ruxience. Our reviewer says that the 
requested drug does not meet the criteria necessary for approval. Our physician reviewer found the Plan 
requires a trial of a tumor necrosis factor antagonist before they will approve the requested drug, Ruxience. 
Based on the medical records and Medicare-approved major drug compendia provided, there is no indication 
that the enrollee has tried and failed the required drug or 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 Ruxience have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ruxience.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861) and accessories (E2622, 
E1012, E2300, E2313, E2620, E2311, E0955, K0108x2, E1007, E2363, E1028x3, E2377, E0953, E0960). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you disagree with the 
denial and request reconsideration. The Plan denied your request. The Plan says the enrollee does not have a 
medical need for multiple power options included with the power wheelchair. The electronic connection, 
expandable controller and harness 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 the enrollee has a normal functioning right upper extremity. Per 
Medicare guidelines, the requested items are not medically necessary as the enrollee has adequate strength to 
manage standard power drives. 
 
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 power wheelchair (K0861) and accessories (E2622, E1012, E2300, 
E2313, E2620, E2311, E0955, K0108x2, E1007, E2363, E1028x3, E2377, E0953, E0960).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on April 23, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says your request is not medically necessary because 
your records did not show that you had chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, your records did not show that you had chronic low 
back pain. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on April 
23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 You asked the Plan to pre-approve Gelsyn-3. You say that you are requesting reconsideration for the denial of 
Gelsyn-3. The Plan denied your request. The Plan says  step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the 
criteria for coverage of Gelsyn-3 have not been met. Our physician reviewer found the Plan requires a trial of 
Orthovisc, Synvisc, Synvisc One or Monovisc 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 provided indicating that the 
Plans required drug(s) would likely be less effective or 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided on April 20, 2023. 
 
You asked the Plan to pay for office visit services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says to receive payment from covered Medicare items or 
services, a provider or supplier must be enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visit 
services provided on April 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary 195mg cap. 
 
You asked the Plan to pre-approve the medication. You say that the medication is needed to treat the enrollee's 
advanced Parkinson's disease. 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 Rytary 195mg cap.  
 
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: 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be met at an alternate 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies. 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 skin substitute (Q4210x80), Axolotl Graft or Axolotl 
DualGraft (Q4259x60), Celera Dual Layer or Celera Dual Membrane (Q4173x80) and PalinGen or PalinGen 
XPlus (97597x10). 
 
You asked the Plan to pre-approve wound care supplies. You say that the requested wound care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the health plan. 
 
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 wound care supplies. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per the documentation, wound characteristics, wound base, fibro-granular fibrous 
with biofilm and slough wound edge, erythematous, hyperkeratotic, and inflamed presence of previous signs of 
infections to the extent of 25% of the tissue. Presence of necrosis, revitalized, or nonviable tissue extend of 
over 25% of the wound. Mild odor, serosanguinous exudate. Wound measures 1.5 centimeters (cm) length (L) 
x 1.4cm width (W) x 0.2cm (D) x 0.42cm (Volume). The wound has been debrided. Axolotl, Celera, and 
PalinGen skin substitutes are unproven and not medically necessary secondary to insufficient evidence of 
efficacy. The review has determined that the items/services at issue in this case are not medically reasonable 
and necessary. The enrollee does not meet medical necessity criteria for the requested wound care supplies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skin substitute (Q4210x80), Axolotl Graft or Axolotl DualGraft (Q4259x60), 
Celera Dual Layer or Celera Dual Membrane (Q4173x80) and PalinGen or PalinGen XPlus (97597x10).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are 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 home health services Our physician reviewer found the documentation does not support that the 
enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The 
enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or 
services in order to improve the enrollees condition, perform a maintenance program to maintain the enrollees 
condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 home health skilled nursing visits.
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 these services will help you regain your strength and 
abilities. The Plan denied your request. The Plan says the required services can be provided in an alternate 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies. 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 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 you require an IRF admission to regain your full 
level of function. The Plan denied your request. The Plan says the enrollee's condition 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 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 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing. 
 
You asked the Plan to pre-approve radionuclide stress testing. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee is asymptomatic. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the 
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or 
abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered 
screening and denied as not covered by Medicare. 
 
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 radionuclide stress testing. Our 
reviewer says that the requested radionuclide stress testing is not medically necessary. Our physician reviewer 
found the enrollee reported no cardiac signs or symptoms at the recent documented office visit. There is no 
evidence provided that would support the need for radionuclide stress testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radionuclide stress testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radionuclide stress testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acitretin. 
 
You asked the Plan to pre-approve the medication. You say that the records provided support medical 
necessity. 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 acitretin.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 27, 2023, to 
July 25, 2023.  
 
You asked the Plan to pay for home health services. You say that the home health services were 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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found the enrollee's chronic 
medical condition was stable without reasonable expectation of decline. Therefore, there was no indication for 
continued 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 pay for the home health services provided from June 27, 2023, to July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve primary care services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says they are unable to approve your request to see 
out-of-network providers past the 90 days of your enrollment with the Plan. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
primary care services to be provided by an out-of-network (OON) provider.