Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (including any 
clasps, rests and teeth) (D5226) and maxillary partial denture - flexible base (including any clasps, rests and 
teeth) (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that you requested an appeal for the denied 
dentures. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The services are not listed in your Preventive & Comprehensive 
Dental Coverage Customer Handbook as a covered benefit; therefore, the services are not covered. Therefore, 
we decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (including any 
clasps, rests and teeth) (D5226) and maxillary partial denture - flexible base (including any clasps, rests and 
teeth) (D5225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) of the brain 
(78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the requested PET scan is urgently needed for 
the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found a differential diagnosis of FTD 
versus Alzheimer's disease is not listed in the submitted records. Our physician reviewer found that magnetic 
resonance imaging (MRI) services have not yet been complete. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) of the brain (78608).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Xarelto for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says the member's condition alone is not a 
medically necessary indication for this drug. 
 
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 Prolia. Our reviewer says that 
Dosing recommendations for Prolia state that concomitant oral calcium (1000 mg) and vitamin D (400 to 800 
international units or greater) daily should be given while receiving Prolia. Based on the medical records 
provided the enrollee is only documented as getting 500 mg of oral calcium daily plus an ALIVE Women's 
Gummy daily (calcium content 100 mg based on the manufacturer's website). Our physician reviewer found 
with inadequate calcium intake there is uncertainty as to the safety and efficacy of the Prolia. 
 
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 Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee demonstrates significant impairments in 
mobility, balance, motor control, function, and safety awareness. The Plan denied your request. The Plan says 
the enrollee's care is not complex, and she does not need a team of providers. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is at a maximal assist level for transfers. Gait assessment was not appropriate. The complexity 
of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. Her medical status does not currently require intensive 
physician and nursing oversight only in an IRF. She may benefit from physical and occupational therapy but 
the documentation does not support that the enrollee can tolerate an intensive rehabilitation therapy program 
provided in an IRF given her lethargy and endurance level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D conformal radiation planning for whole brain 
radiation. 
 
You asked the Plan to pre-approve the 3D conformal planning. You say that the planned treatment would be 
best provided using 3D planning. The Plan denied your request. The Plan says this treatment can be achieved 
with complex standard planning such as complex isodose treatment. 3D conformal treatment exceeds medical 
need. 
 
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 3D conformal planning. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found for whole brain radiation -- even when a CT scan is used for treatment planning 
purposes, and when a 3D dose matrix generated -- for billing purposes, it is the accepted standard to bill 2D 
radiation and not 3D radiation. Generally, 3D radiation is necessary when the 2D radiation plan results in 
unacceptable normal tissue dose exposure and toxicity risks (uncommon with palliative treatment). It usually 
implies the need to spare normal tissues in a manner that cannot be achieved with 2D radiation. Even with 2D 
radiation, a CT based plan can be obtained to calculate dose to normal tissues. Based on the information 
provided, the need for 3D radiation has not been substantiated and it would be within the accepted standards of 
care to use 2D radiation. 
 
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 3D conformal planning have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 3D conformal radiation planning for whole brain radiation.
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 is in a sub-acute rehabilitation facility 
and needs to be transferred to level one as soon as possible. The Plan denied your request. The Plan says the 
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met 
safely in a skilled nursing facility, if ordered by the doctor. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and 
occupational therapy but the documentation does not support that the enrollee requires an 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supply allowance for therapeutic CGM, includes all 
supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) and receiver (monitor), 
dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been 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 the DME. Our physician reviewer 
found the criteria require insulin use and 4x/d bg checks. You are not taking insulin and there is no reason 
given why you are unable to use a glucometer to check bgs and why the data from glucomter is insufficient. 
Therefore, criteria for CGM are not 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve supply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply = 
1 unit of service (CPT Code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (CPT Code K0554).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested treatment is not in the order recommended by the National Comprehensive 
Cancer Network. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Nivolumab is FDA 
approved for the treatment of metastatic non-small cell lung cancer that has progressed on or after platinum-
based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression 
(on approved EGFR- or ALK-directed therapy) prior to receiving nivolumab. The enrollee has not had has not 
had full staging or molecular testing for EGFR and ALK which if positive should be used to guide treatment 
prior to immunotherapy. The service is 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nivolumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management 
specialist. 
 
You asked the Plan to pre-approve these services. You say that you need your medication refilled. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network pain management specialist.
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. The Plan 
denied your request. The Plan says that your medical needs could be accomplished in an intermittent basis 
using your Medicare Part B benefits. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. 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 require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pristiq. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Pristiq.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation needs to improve 
strength, endurance, activities of daily living, mobility needs and medical needs requiring daily medical 
oversight. You say that the enrollee will tolerate the three hours of therapy required. The Plan denied your 
request. The Plan says the request 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 above. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
says that the enrollee may benefit from multiple therapies such as physical and occupational therapy but the 
documentation does not support that the patient requires an 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 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapy needs can continue to be provided at a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for community acquired 
pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 for the enrollee.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. 
 
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 was admitted to the current acute care hospital with acute on chronic 
respiratory failure and pneumonia. She required mechanical ventilation in the ICU. Later she was able to be 
extubated and be on high flow oxygen and BiPAP at night. She is still being treated with antibiotics and 
antifugal medication and requires weaning down on oxygen supplementation and nutritional support. Her 
prognosis is poor with nectrotizing pneumonia and is not a surgical candidate. She requires weaning from 
BiPAP and is gradually improving. The enrollee does not require services in the LTACH that are not available 
in the current setting. There are no services in the LTACH that the enrollee requires which are not already 
available and covered in the current setting. Transfer may be considered at a later date when the enrollee is 
more stable. 
 
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.