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

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's 
cancer. The Plan denied your request. The Plan says Keytruda is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with non-small-cell lung carcinoma who has progressed with Imfinzi. Because the patient has 
previously tried and failed a previous PD-1 inhibitor, the request for Keytruda cannot be approved 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because proton beam therapy is not indicated for the enrollee's type of cancer. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while some may argue that it is standard practice to treat prostate cancer with proton 
beam therapy, both the American Society for Radiation Oncology (ASTRO) and National Comprehensive 
Cancer Network (NCCN) recommend against routine use of proton therapy. Proton therapy would exceed the 
enrollee's medical needs. Proton therapy may or may not be better than intensity-modulated radiation therapy 
(IMRT) or image-guided radiation therapy (IGRT). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the requested inpatient or outpatient hospital services. 
 
You asked the Plan to pre-approve the requested inpatient or outpatient hospital services. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has provided a very limited case file. The prior authorization request in 
the file is for initial observation care in an outpatient setting; however, the Plan final determination letter is 
denying payment for inpatient services. A request was made to the Plan to send the missing information needed 
for the case file in order to decide if the Plan's denial is correct based on Medicare criteria. The Plan failed to 
respond to our request and have not provided the necessary information. We are unable to determine if the 
request is for outpatient or inpatient services, if the appeal is in regard to a denial of payment as indicated in the 
Plan's final determination letter, or if the enrollee has already received the requested services which would 
make a pre-service appeal request invalid. Therefore, we decided that the Plan has to pre-approve the requested 
inpatient or outpatient hospital services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH). 
Initially treated for hematuria, the enrollee's hospitalization was complicated by endocarditis. The enrollee had 
been tolerating oxygen via nasal cannula but was recently intubated/ventilated for hospital acquired pneumonia 
and promptly received a tracheotomy. Attempts at weaning have not yet been documented. There is no 
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed 
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee 
can remain at the current ACH until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 cervical/thoracic interlaminar epidural.

You asked the Plan to pre-approve cervical/thoracic interlaminar epidural. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve cervical/thoracic interlaminar epidural. 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 chronic neck pain with radiation into the arms bilaterally. The enrollee had a cervical epidural steroid injection which has provided at least 7 weeks of pain relief. The enrollee is doing a Home exercise program. There is no note that details the recurrence of the enrollee's pain. Therefore, the enrollee does not meet criteria for the requested 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 cervical/thoracic interlaminar epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical/thoracic interlaminar epidural.
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 there is no 
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the 
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital services. 
 
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 surgery is approved but the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that 
the inpatient services are not medically necessary. Our physician reviewer found the enrollee is approved for an 
elective left shoulder arthroplasty. He is medically stable and has been provided medical clearance for the 
procedure. The records do not support that he will require at least two midnights of inpatient hospital care for 
the approved procedure. The inpatient level of care 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a consultation with an out-of-network tertiary level oral 
maxillofacial surgeon. 
 
You asked the Plan to pre-approve a consultation with an out-of-network tertiary level oral maxillofacial 
surgeon. You say that your father needs surgery and is in a lot of pain and cannot close his mouth. You say that 
the requested care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says that the requested services are not necessary, and the enrollee has been approved to see an in-network 
hand and plastic surgery specialist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
We looked at the file and Medicare rules. The Plan must arrange for specialty care outside of the plan provider 
network when network providers are unavailable or inadequate to meet an enrollee's medical needs. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. The file does not show that the Plan has network oral maxillofacial surgeons to treat the 
enrollee's cancer of the mandible (jaw or jawbone). Based on this information, we decided that Medicare rules 
for coverage of a consultation with an out-of-network tertiary level oral maxillofacial surgeon have been met. 
Therefore, we decided that the Plan has to pre-approve a consultation with an out-of-network tertiary level oral 
maxillofacial surgeon.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the initial ophthalmology consultation and eye 
examinations (99204, 92025, 92025 and 76512) with an out of network provider. 
 
You asked the Plan to pre-approve the vision services. You say that you are established with this provider and 
it is only a half mile away from your home and easy to set an appointment. The Plan denied your request. The 
Plan says enrollee's must receive their vision services from an in-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by the designated in-network vendor. 
 
We looked at the file and the Plan's rules. enrollee's must receive their vision services from an in-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the initial ophthalmology 
consultation and eye examinations (99204, 92025, 92025 and 76512) with an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to noble metal crown (D2750) for tooth # 29.
You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied your request. The Plan says porcelain fused to noble metal crown is not a type of covered crown.
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, porcelain fused to noble metal crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to noble metal crown (D2750) for tooth # 29.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650) provided October 26, 2020.
You asked the Plan to pre-approve the orthosis. You say that the brace was medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. Medicare rules prohibit payment to a supplier that knowingly submits a claim generated pursuant to a prohibited telephone solicitation. We looked at the file and Medicare rules. The plan documentation shows the brace was provided as the result of a telephone solicitation. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650) provided October 26, 2020.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 
enrollee does not meet criteria for IRF admission. 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 acute hypoxic respiratory 
failure, asthma exacerbation, and unprovoked pulmonary embolism. 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, in 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. 
 
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 continuation of psychotherapy to be provided by the 
out-of-network provider. 
 
You asked the Plan to pre-approve continuation of psychotherapy to be provided by the out-of-network 
provider. You say that there should have been a transition of care as you suffer from psychiatric brain trauma 
issues. You say that prior to the Plan enrollment, you had been seeing this provider for seven years. You say 
that this provider is nearby and providers under the Plan's group would be too far. The Plan denied your 
request. The Plan says you must receive your care from a network provider. In most cases, care you receive 
from an out-of--network provider (a provider who is not part of our plan's network) will not be covered. The 
Plan also says that the in-network provider's office is just 10 minutes farther than the doctor you have 
requested. The distance is within 30 minutes of your home, which is within the Medicare acceptable standard 
for accessibility. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 continuation of psychotherapy to be 
provided by the out-of-network provider. Our reviewer says that continuation of psychotherapy to be provided 
by the out-of-network provider is not medically necessary. Our physician reviewer found that there is no 
documentation of an emergency or urgent care and there is a provider available in-network who can treat your 
condition. Based on review the medical records provided you do not require treatment by an out-of-network 
provider as the Plan is able to provide a psychotherapist for the treatment of your condition. Your condition is 
not considered urgent/emergent. Utilization of an in-network provider assures a credentialed and clinically 
maintained individual assured by the medical provider to a certain standard 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 continuation of psychotherapy to be provided by the out-of-network provided 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of 
psychotherapy to be provided by the out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing visits (6) and 
physical therapy visits (8). 
 
You asked the Plan to pre-approve additional home health skilled nursing visits (6) and physical therapy visits 
(8). You say that the additional home health skilled nursing visits (6) and physical therapy visits (8) are 
medically necessary. The Plan denied your request. The Plan says the additional home health skilled nursing 
visits (6) and physical therapy visits (8) are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional home health skilled nursing 
visits (6) and physical therapy visits (8). Our reviewer says that the additional home health skilled nursing 
visits (6) and physical therapy visits (8) are not medically necessary. Our physician reviewer found in this case, 
the documentation does not support that the member requires skilled nursing services or skilled rehab services 
to provide treatment that is medically necessary. The member does not require skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve the member?s condition, perform a 
maintenance program to maintain the member?s condition and/or prevent deterioration.  The member has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  He 
received skilled physical therapy with improvement in function, his goals were met, and therapy was 
discontinued.  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 additional home health skilled nursing visits (6) and physical therapy visits (8) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health 
skilled nursing visits (6) and physical therapy visits (8).