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

 
We decided that the Plan has to pre-approve Keytruda 
 
You asked the Plan to pre-approve Keytruda. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says that the continued use of the requested drug after 
disease progression on that drug is not supported. 
 
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 Keytruda. Our reviewer says that 
Keytruda is medically reasonable and necessary in this case. Our physician reviewer found the use of Keytruda 
is FDA-approved for the enrollee's diagnosis. However, our physician reviewer also found that it is only 
approved as a single agent and not in combination with Efortumab. The documentation supports that the 
requested drug is safe, effective, and otherwise reasonable and necessary for the enrollee, but only as a single 
agent. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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 a CardioMEMs HF System. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
hyperlipidemia, hypertension, obesity, diabetes, coronary artery disease, ischemic cardiomyopathy, defibrillator 
placement and NYSHA Class III congestive heart failure with reduced left ventricular ejection fraction (less 
than 35 percent) requiring hospitalization. The efficacy of the CardioMEMS device is uncertain at this time, 
according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. 
The device is considered experimental or investigational and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs HF System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR). 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TAVR is covered when specific criteria are 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 these services.  
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has 
aortic valve stenosis that is not documented to be symptomatic. Moreover, valve gradients are not in a severe 
range (peak > 64mmHg and mean > 40mmHg) and were near identical to the prior echocardiogram where the 
valve area was calculated only moderately reduced at 1.0cm2. Finally, the documentation does not support that 
a multidisciplinary heart team consisting of an interventional cardiologist and independent cardiac surgeon 
have evaluated the enrollee. The TAVR is therefore 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 a transcatheter aortic valve replacement (TAVR).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 home health skilled nursing visits. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 not medically necessary. Our physician reviewer found the you have been receiving skilled 
care since March of 2020. There is no indication that you have had a recent hospitalization or change in 
functional status. There are no skilled nursing needs such as complex wound care, parental medications or care 
of a feeding tube. You have been medically stable without acute exacerbations of chronic medical conditions. 
You do not require skilled nursing to effectively provide treatment, care, and/or services in order to improve 
your condition or to perform a maintenance program to maintain your condition and/or prevent deterioration. 
 
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 15 home health skilled nursing visits.
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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria for IRF care has not been met. 
 
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 admission to an IRF is not medically necessary based on lack of medical complexity 
and current functional status. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria. 
 
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 there is no evidence that the enrollee requires services that are not currently available.  
As LTACHs and acute hospital 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 acute hospital until such time 
no acute services are required. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not appear to be stable enough for transfer due to leukocytosis, low 
blood pressures, and fever. Continued care at the current facility is most appropriate. The patient does not 
require any services at the LTACH that are not available at the current facility. 
 
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 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 the requested 
admission to an IRF. 
 
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 
enrollee does not meet criteria for the requested admission to an IRF. Our physician reviewer found based on 
the documentation provided, the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollee's care needs can be met at a lower 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: 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 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 
enrollee does not meet criteria for IRF admission. 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. The enrollee's medical status and medical conditions do not 
currently require intensive physician and nursing oversight only in an IRF.  The enrollee may benefit from 
multiple therapies such as physical and occupational therapy but the documentation does not support that the 
enrollee'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 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 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 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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician 
evaluation.  The enrollee's care needs can be met at a lower 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: 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 for replacement of ICD/PM due to recurrent fungemia and sepsis. He was diagnosed with heart failure. He required antibiotics, hemodialysis, and milrinone drip. He has since completed antibiotic and anti-fungal medication courses, although still requires hemodialysis and physical therapy moving forward. Vitals have been stable, however, signs of encephalopathy continue to aggravate the enrollee, requiring antipsychotic medications. The enrollee in this case appears to be still requiring short-term acute care services. It does not appear, however, that he will require acute care services for more than 24 days. The enrollee does not require any services at the LTACH that are not already available at the current facility. There are no 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of proton beam therapy is not 
routinely recommended for the treatment of prostate cancer outside of a prospective clinical trial or registry. 
There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other 
forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this 
expensive therapy. Any potential benefit of proton beam therapy over standard intensity-modulated radiation 
therapy (IMRT) for routine cases is investigational in nature and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (CPT 95811). 
 
You asked the Plan to pre-approve the sleep study. You say that without a CPAP the enrollee will wake up 
gasping and choking. You say that the enrollee would stop breathing and it is imperative that he has this sleep 
study done. The Plan denied your request. The Plan says the sleep test 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 sleep study. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has already been diagnosed with obstructive sleep apnea. The Sleep Disorder 
Center note dated July 6, 2020 noted concern for obesity hypoventilation syndrome, as the enrollee is having 
symptoms of hypoventilation. Per the documentation, he has a CPAP machine but it is not functioning 
properly. It is not known what is exactly wrong with the patient's current CPAP machine or if it is repairable. 
The NCD coverage criteria for sleep testing are not met in this case, as the study is not being performed to aid 
in the diagnosis of obstructive sleep apnea. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (CPT 95811).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluorouracil. 
 
You asked the Plan to pre-approve Fluorouracil. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Fluorouracil is not covered under the enrollee's Medicare 
Part B 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 Fluorouracil.  
 
Benefits for Fluorouracil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroxychloroquine 200mg tablets. 
 
You asked the Plan to pre-approve Hydroxychloroquine. You say that this drug is medically necessary. The 
Plan denied your request. The Plan says Hydroxychloroquine is not eligible for coverage under the Part B 
medical 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 Hydroxychloroquine 200mg 
tablets.  
 
Benefits for Hydroxychloroquine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.