Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the current acute care hospital with GI bleed and was treated with blood transfusion. 
She was diagnosed with C. diff and required antibiotics, BiPAP, oxygen, and diuresis. The course was 
complicated by cor pulmonale, atrial fibrillation, hypotension, ongoing anemia, volume overload and shortness 
of breath as well as hyperkalemia and hyponatremia. The enrollee is still requiring midodrine, still has edema, 
but has improving breathing status. 
 
The enrollee appears to be improving gradually but additional short term acute care services (likely less than 25 
days) are still needed to further stabilize, which can be completed in the current setting. The enrollee does not 
require services at the LTACH that are not already available at the current setting. There are not services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electromagnetic navigational bronchoscopy (ENB). 
 
You asked the Plan to pre-approve ENB. You say that the requested electromagnetic navigational 
bronchoscopy (ENB) is medically necessary. The Plan denied your request. The Plan says the requested 
electromagnetic navigational bronchoscopy (ENB) 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 ENB. Our reviewer says that the 
requested electromagnetic navigational bronchoscopy (ENB) is not medically necessary. Our physician 
reviewer found the enrollee is with a chronic cough and radiographic abnormalities concerning for malignancy. 
The enrollee was found to have a large right lower lobe mass. The provider has requested ENB for biopsy. For 
ENB, currently high level evidence is limited and its position in the diagnostic algorithm for biopsy remains 
unclear. The request is not medically necessary 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 ENB have not been met. Therefore, we decided that the Plan does not have to 
pre-approve electromagnetic navigational bronchoscopy (ENB).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the additional mileage is 
needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. 
Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips per calendar year when each one-way trip does not 
exceed 50 miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro solution 1800/30,000mg-ut/15ml 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 this is not medically necessary. 
 
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 in this case, the enrollee 
has not tried either Revlimid or Velcade and had only failed one proteasome inhibitor treatment (Ninlaro). 
Therefore, without sufficient evidence that this patient had an FDA-approved indication for this medication 
supported by literature, the Darzalex will be considered not medically necessary at this time. There isn't 
sufficient evidence of safety and effectiveness for the enrollee using Darzalex in this specific clinical situation. 
 
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 Darzalex Faspro solution 1800/30,000mg-ut/15ml for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested spinal surgery is medically 
necessary. The Plan denied your request. The Plan says the requested spinal surgery 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 spinal surgery. Our reviewer says that 
the requested spinal surgery is not medically necessary. Our physician reviewer found the enrollee is with 
cervical degenerative disease, cervical radiculopathy, and multi-level cervical disc herniation refractory to 
conservative treatment who previously underwent cervical surgery on October 8, 2012. Criteria for multilevel 
cervical fusion are not met. There is no spinal instability. There is no neurologic deficit. Fusion surgery is not 
medically needed 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has chronic respiratory failure 
secondary to chronic obstructive pulmonary disease. The Plan denied your request. The Plan says the ventilator 
will not be providing continuous ventilatory support. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our physician reviewer 
found that the enrollee was hospitalized because of hyponatremia. He was not short of breath on admission.  
The diagnosis of COPD is not supported by pulmonary function tests. He developed acute respiratory failure 
and renal failure during the hospitalization. He improved with CPAP. He is morbidly obese with loud snoring 
and observed apneas in the hospital. At this time, it is unclear whether he retains CO2 when medically stable, 
or whether he has COPD.  If he does retain CO2, the appropriate treatment is nocturnal BiPAP. Certain BiPAP 
devices are capable of providing the AVAPS mode of support that has been ordered. Medicare does not cover a 
portable ventilator when used as BiPAP.  Therefore, a portable ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says custodial care is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse or a qualified therapist is not required to safely and effectively provide medically 
necessary and reasonable treatment. Based on the medical records provided, you do not require the services on 
an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis 
appear appropriate in this case. 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that a ventilator is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records 
show you have been hospitalized for recurrent respiratory infections and has bronchiectasis.  The diagnosis of 
COPD is not supported by spirometry results.  There is no ABG demonstrating CO2 retention.  There is no 
evidence for generalized neuromuscular disease of thoracic restrictive disease. You have not failed a BiPAP.  
Medicare does not cover a home ventilator when used as BiPAP, and certain BiPAP devices are capable of 
providing the AVAPS mode of support that has been requested.  A home ventilator is not medically necessary, 
and the denial is upheld. 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 ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a ventilator.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says this request is not covered by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles one-way. 
 
We looked at your request, the records in the case file, and the rules. Additional miles over 50 cannot be 
covered. Based on this information, we decided that the Plans rules for coverage of routine transportation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS. You say that you are in extreme pain and need this replaced 
quickly as it has provided good relief in the past. The Plan denied your request. The Plan says there is no 
documentation of a current psychological evaluation. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
Although there is a note indicating that evaluation was planned, the file does not show that a psychological 
evaluation has been conducted in conjunction with this request for a spinal cord stimulator trial. Record of 
psychological clearance must be included in the record. Therefore, we decided that the Plan does not have to 
pre-approve replacement of a spinal cord stimulator (SCS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of GammaGraft for wound healing. 
 
You asked the Plan to pre-approve the GammaGraft placement. You say that the requested treatment is not 
experimental or investigational but is the Gold Standard for treatment wounds. The documentation shows that 
this is FDA-approved and appropriate for use in this case. The Plan denied your request. The Plan says the type 
of product being requested is considered investigational for the type of wound that the enrollee has. The Plan 
says that the requested treatment 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 GammaGraft placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is an 88-year-old man with a 1 x 1.5 cm melanoma in situ on the left 
upper lip. The provider determined that the enrollee needed a wide local incision with 5 mm margins, and 
likely staged reconstruction with initial placement of GammaGraft. It has not been adequately demonstrated 
that GammaGraft (donated human skin) is likely to be safe and effective, and medically reasonable and 
necessary in this 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 the GammaGraft placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of GammaGraft for wound healing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ultrasonic bone growth stimulator. 
 
You asked the Plan to pre-approve a ultrasonic bone growth stimulator. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that osteogenesis stimulators are covered when specific 
criteria is 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 a ultrasonic bone growth stimulator. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation 
does not reveal nonunion of a long bone fracture documented by a minimum of two sets of radiographs 
obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each 
including multiple views of the fracture site with written interpretation by a treating practitioner stating that 
there has been no clinically significant evidence of fracture healing between the two sets of radiographs. The 
documentation does not support that the criteria has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ultrasonic bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a ultrasonic bone growth stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin (J9355) and Palonosetron (J2469). 
 
You asked the Plan to pre-approve Herceptin and Palonosetron. You say that the medications are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
 
 
 
 
In this case, you asked the Plan to pre-approve Herceptin and Palonosetron as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve Herceptin (J9355) and Palonosetron (J2469).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLantus Solostar.You asked the Plan to pre-approveLantus Solostar. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveLantus Solostar.Benefits for Lantus Solostarmay be available under Medicare Part D.Contactthe 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 the records provided support the need for IRF care. 
IRF admission would optimize the enrollee's level of functioning prior to her returning home. The Plan denied 
your request. The Plan says guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee's needed care is not complex enough and can be provided at a lower level. 
 
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 is a female who was admitted on 10/15/2020 with worsening cellulitis 
and toe pain, with fever and chills. MRI revealed acute osteomyelitis of several bones of the foot and septic 
arthritis. The patient was started on Vancomycin and Cefepime IV eventually started on Rocephin. She 
underwent debridement of the infected bone on 10/20/2020. Occupational therapy found she needs max assist 
for lower body dressing and daily living activities, and she is weightbearing as tolerated. Ambulation is limited 
by pain and fatigue. 
 
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not 
 
 
currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from 
multiple therapies such as physical and occupational therapy but the documentation does not support that the 
patient's functional status requires or can tolerate 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.