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

 
We decided that the Plan has to pre-approve abraxane and Udenyca. 
 
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 that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has stage III pT2N2 pancreatic 
cancer and is status-post Whipple procedure. Gemcitabine and abraxane are a standard regimen for the 
adjuvant treatment of pancreatic cancer. The enrollee has a stage III pancreatic cancer found after resection. In 
addition, a growth factor such as Udencya would not be unreasonable given recent surgery and aged over 65. 
The services are safe and effective and reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve abraxane and Udenyca.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent pain pump implant. 
 
You asked the Plan to pre-approve pain pump. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this item is correct, because the enrollee already has 
an implanted spinal cord stimulator and therefore this pain pump is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an implanted pain pump is contraindicated for 
enrollees with other implanted programmable devices and is not covered under such a circumstance.  
 
We looked at the file and Medicare rules. The enrollee already has an implanted programmable device; 
therefore, implantation of a pain infusion pump is contraindicated at this time. Based on this information, we 
decided that Medicare rules for coverage of pain pump have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a permanent pain pump implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy - molar, tooth 
#14 (D3348). 
 
You asked the Plan to pre-approve the dental services. You say that you went to the dentist two (2) days after 
experiencing much discomfort and not being able to chew on your left side. The Plan denied your request. The 
Plan says the service is 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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve retreatment of previous root 
canal therapy - molar, tooth #14 (D3348).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
September 16, 2020. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee needs more therapy and 
you feel that it will not be provided in long term care. The Plan denied your request. The Plan says the enrollee 
no longer needs daily skilled care. 
 
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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 86 year 
old male with atrial fibrillation, pacemaker and hip fracture admitted to the SNF. From a nursing perspective, 
the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation 
services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at an 
independent to contact guard/minimal assist level with functional mobility including gait to 60 feet with a 
rolling walker. The beneficiary required varying assist with ADLs. 
 
The enrollee no longer requires skilled nursing or skilled therapy services. This beneficiary does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond September 16, 2020.
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 the requested services. The Plan denied your request. The Plan says the 
treatment is not supported for the enrollee's cancer type during a boost phase. 
 
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 requested services. Our physician 
reviewer found that for this enrollee, only the IMRT for the boost phase is disputed. There is no rationale for 
the need for IMRT in this enrollee, and specifically for the boost phase. There is no plan comparison provided 
in this case. Due to lack of demonstration of need, and not being in accordance with accepted standards to 
routinely use IMRT, the requested services are not medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a I-131 MIBG scan (78802). 
 
You asked the Plan to pre-approve the I-131 MIBG scan. You say that the imaging is medically necessary. The 
Plan denied your request. The Plan says coverage criteria is not met. 
 
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 I-131 MIBG scan. Our reviewer 
says that the requested scan is not medically necessary. Our physician reviewer found based on the records the 
enrollee had a thorough evaluation that was completely negative for pheochromocytoma. In this circumstance 
the records do not support the medical necessity for an I-131 MIBG scan. An 1-131 MIBG scan would be 
indicated only if there were evidence of elevated catecholamines and the location of a pheochromocytoma 
could not be identified with standard imaging or if testing for catecholamines were inconclusive, neither of 
which is the case in this instance. 
 
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 I-131 MIBG scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a I-131 MIBG scan (78802).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like to continue care with this 
provider. The Plan denied your request. The Plan says the services can be performed in-network. 
 
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 
the medical services to be provided by an out-of-network provider.
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 needs intensive rehab to re-establish 
baseline mobility. You say that the enrollee was incorrectly placed in a skilled nursing facility. The Plan denied 
your request. The Plan says the enrollee's needs can be met 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. Our 
physician reviewer found that there are no complex nursing or rehabilitation needs. Our reviewer says that the 
medical records support a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. 
 
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. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee's medical status does not currently require intensive physician and nursing oversight 
only in an IRF. Our physician reviewer also found that the enrollee may benefit from multiple therapies such as 
physical and occupational therapy, but the documentation does not support that the enrollee's functional status 
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: Favorable

 
We decided that the Plan has to pre-approve inpatient admission for the approved surgery. 
 
You asked the Plan to pre-approve inpatient admission for the approved surgery. You say that the requested 
inpatient admission for the approved surgery is medically necessary. The Plan denied your request. The Plan 
says that the requested inpatient admission for the approved surgery is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 inpatient admission for the approved 
surgery. Our reviewer says that the requested inpatient admission for the approved surgery is medically 
necessary. Our physician reviewer found the enrollee has been approved for 3-5 level lumbar fusion surgery. 
This is an extensive and risky operation. Most patients who have this procedure stay 3 days as an inpatient due 
to the post-op increased risks of the surgery. The inpatient admission should be approved in this case of 
extensive multilevel lumbar fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for the approved surgery have been met. Therefore, we 
decided that the Plan has to pre-approve inpatient admission for the approved surgery.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 appears too unstable at this point to transfer, having worsening mental 
status changes and ongoing feeding tube requirements. The enrollee does not require services at the LTACH 
that are not already being provided at the current facility. Therefore, this request for LTACH services is not 
considered medically necessary at this time. Transfer may be considered at a later date when the enrollee is 
more stable and suitable for transfer. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Azopt Sus 1% Op. 
 
You asked the Plan to pre-approve the medication. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. The Plan benefits say this medication falls under Part D coverage, but the member has no Part 
D pharmacy benefit. This medication does not fall under Part B. The Plan confirmed also that the member has 
no commercial pharmacy benefit administered by the Plan. Therefore, we decided that the Plan does not have 
to pre-approve Azopt Sus 1% Op.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 based on the documentation provided, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional routine transportation trips. 
 
You asked the Plan to pre-approve six (6) additional routine transportation trips. You say that you are 
requesting review of denial of services. The Plan denied your request. The Plan says the enrollee's benefit 
allows 30 trips for this service. The Plan states the enrollee has used 29 transportation trips and currently has 1 
trip remaining. 
 
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 a maximum of thirty (30) one-way trips 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. The enrollee has one 
trip remaining of their 30 covered trips. The 31st trip and beyond is not a covered benefit. The enrollee's EOC 
states routine transportation for up to 30 one-way transportation trips per calendar year, limited to ground 
transportation only to destinations within 50 miles of the pickup location. Therefore, we decided that the Plan 
does not have to pre-approve six (6) additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care. 
 
You asked the Plan to pre-approve continuation of SNF care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says you have used more skilled nursing facility days than are covered 
under your Plan during your current benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from May 21, 2020 through 
August 21, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that this has proven to be an effective 
treatment option for patients suffering from radicular pain. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because the enrollee does not have a condition for which this 
treatment is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is only covered for the 
indications listed 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested spinal cord stimulator. Our 
physician reviewer found the enrollee has had trials of physical therapy, epidural steroid injections, facet joint 
injections, medication trials, opioids, and topical analgesics. She had a psychological evaluation which cleared 
her for a spinal cord stimulator trial. She has not had an intrathecal opiate trial. The enrollee does not have an 
evidence-based indication for a spinal cord stimulator. Therefore, the requested procedure is not medically 
reasonable or 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of a spinal cord stimulator.