Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve IMRT. You say that the requested IMRT is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IMRT.
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 IMRT. Our reviewer says that the enrollee does not meet criteria for IMRT. Our physician reviewer found 3D conformal meets all accepted dosimetric constraints which would be accepted for a standard whole breast radiotherapy plan for the treatment of right sided breast cancer with no exceptional circumstances. In this case, it is safe to say that IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose distribution in select patients when the dose-volume exposure of the heart and lungs warrant its use and/or patients in which the skin has excessive hot spots for which IMRT could result in a more homogeneous dose distribution. For IMRT to be medically necessary, an appreciable benefit must be achieved. IMRT can be considered medically necessary when a clinically meaningful reduction in normal tissue dose exposure can be achieved. For this enrollee, such a benefit would not be plausible and was not demonstrated in the case records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ativan. 
 
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 self-administered drugs are not a covered benefit. 
 
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 Ativan.  
 
Benefits for these services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine transport trip. 
 
You asked the Plan to pre-approve the transport trip. You say that you need transportation to the appointment. 
The Plan denied your request. The Plan says the destination exceeds the 50 mile limit noted in the plan 
contract. 
 
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 routine transportation when the distance is within a 50-mile limit.  
 
We looked at your request, the records in the case file, and the rules. The destination is 74.58 miles away. This 
exceeds the 50 mile limit. Based on this information, we decided that the Plan's rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine 
transport trip.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, wound care, and daily therapy can be provided at a SNF. The member is mostly MODERATE 
assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for 
measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. The member is mostly TOTAL/MAX assist for 
functional transfers and ADL?s and a less intensive, longer duration of therapy may be more appropriate. It is 
not clear the member would be able to fully benefit and/or participate in an IRF 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care. 
 
You asked the Plan to pre-approve the continued inpatient mental health care. You say that you would like 
reconsideration because the continued care is medically necessary. The Plan denied your request. The Plan says 
the enrollee is no longer a threat to himself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
care. Our reviewer says that this enrollee did not require inpatient mental health treatment beyond the dates in 
question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or 
visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did 
not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the patient?s condition or for the purpose of diagnosis. Our physician reviewer found this member 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of September 1, 2020 forward and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing 
any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 
 
 
 
 
 
 
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 continued inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health care.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital on August 27, 2020 for scheduled 
amputation of necrotic toes. He 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 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connector to 2 power options. 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connector to 2 power 
options. You say that the items which remain in dispute are medically necessary. The Plan denied your request. 
The Plan says the enrollee's upper limb function is adequate for the enrollee to be able to control the power 
options using their own switches, which are included in the allowance for the approved power options. 
 
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 an expandable controller, harness, and 
electronic connector to 2 power options. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case 
file notes that the enrollee has 4+ strength in her right upper extremity. The documentation does not support 
that there is a medical need to control the power options on the enrollee's wheelchair through a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and electronic connector to 2 power options 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
harness, and electronic connector to 2 power options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cell phone/media holder, electronic connection, and 
expandable controller with harness. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested cell phone/media holder does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured and is not 
covered by Medicare. 
 
The requested electronic connection and expandable controller with harness are not needed for the approved 
PWC. The approved power options are sufficient to meet the enrollee's needs. 
 
Therefore, we decided that the Plan does not have to pre-approve a cell phone/media holder, electronic 
connection, and expandable controller with harness.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the hospital on July 13, 2020. His hospital course has 
been complicated by a heart attack, liver abscess after IR drainage, a gastrointestinal bleed and 
hemorrhoidectomy, and left leg ischemia resulting in dry gangrene of his left foot and leg. The enrollee still 
requires acute hospital level of care service and is receiving appropriate care at the present acute care hospital. 
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 and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the pelvis. 
 
You asked the Plan to pre-approve a CT scan of the pelvis. You say that the requested CT scan of the pelvis is 
medically necessary. The Plan denied your request. The Plan says the requested CT scan of the pelvis is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the pelvis. Our reviewer 
says that the requested CT scan of the pelvis is not medically necessary. Our physician reviewer found the 
enrollee is with bilateral flank pain, and urinary incontinence. No hematuria or pelvic pain. Normal PSA of 1.4 
ng/mL. Treatment for BPH initiated with tamsulosin. Request is for coverage of CT scan of the pelvis. The 
medical records do not provide a clinical reason for CT scan of the pelvis. A CT scan of the pelvis is not 
indicated for the evaluation of BPH (N40.1). 
 
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 CT scan of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the pelvis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kadcyla (J9354). 
 
You asked the Plan to pre-approve Kadcyla. You say that Kadcyla is medically necessary. The Plan denied 
your request. The Plan says this drug is not approved for the enrollee's diagnosis. 
 
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 Kadcyla. Our reviewer says that 
Kadcyla is not medically necessary. Our physician reviewer found the use of Kadcyla for either unknown 
primary or for any type of urothelial cancer is not FDA approved. The use is not supported in any of the CMS 
approved compendia. The reviewer did not find any supporting citations in a PubMed search. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kadcyla have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kadcyla (J9354).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MPI SPECT. 
 
You asked the Plan to pre-approve an MPI SPECT. You say that the requested MPI SPECT is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
MPI SPECT. 
 
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 an MPI SPECT. Our reviewer says that 
the enrollee does not meet criteria for the requested MPI SPECT. Our physician reviewer found based on the 
records the enrollee has some coronary risk but no chest discomfort, nonspecific exertional dyspnea that has 
not clearly changed, no specific ischemic electrocardiographic changes, no ischemia on prior stress testing, no 
wall motion abnormalities on echocardiogram 1 year ago and scheduled for low risk non-cardiac surgery.  In 
this circumstance the records do not support the medical necessity for repeat nuclear stress testing.  Current 
guidelines endorsed by several national organizations also do not consider preoperative nuclear stress testing 
appropriate in this setting.  In addition, coverage criteria are not met since there is no documented covered 
indication for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MPI SPECT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MPI SPECT.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 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. She was 
admitted for COVID 19 pneumonia. Her medical problems are stable. There are no complex nursing or 
rehabilitation needs. 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. IRF care 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 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 would like reconsideration because you have a 
broken hip and this care is medically necessary. The Plan denied your request. The Plan says you do not meet 
criteria for inpatient rehabilitation 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 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. There are no complex nursing or rehabilitation needs. 
Our physician reviewer found 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.