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

 
We decided that the Plan does not have to pre-approve bilateral breast magnetic resonance imaging (MRI). 
 
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 MRIs 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is undergoing evaluation 
for left axillary discomfort. An ultrasound was performed on March 10, 2020 that noted benign-appearing 
lymph nodes in the left axilla. Physical exam n January 12, 2021 noted no masses or tenderness in the left or 
right breast. In this case, the only exam accepted for breast cancer screening is mammography. Breast MRI is 
medically appropriate when utilized in conjunction with a mammogram and is to be used very selectively. The 
enrollee has not yet completed a standard work-up as the screening mammogram and screening ultrasound 
have not been completed. The MRI 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 bilateral breast magnetic resonance imaging (MRI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
still requires acute hospital level of care services and 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that this service is medically 
necessary. The Plan denied your request. The Plan says return to competency services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for services furnished to 
individuals or groups of individuals who are in the custody of police or other penal authorities or in the custody 
of a government agency under a penal statute only if certain conditions are met. 
  
We looked at the file and Medicare rules. The file indicates that the enrollee is in custody and does not meet the 
exceptions for when Medicare can cover services for an enrollee in custody. Based on this information, we 
decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this will reduce your pain and help your 
continuous exercise. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex surgery (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex surgery. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the Vertiflex Superion Interspinous device is not medically necessary 
and is experimental/investigational. 
 
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 Vertiflex surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer remains experimental. More research is needed to show safety and 
efficacy of the spacer device. 
 
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 Vertiflex surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex surgery (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance tablets. 
 
You asked the Plan to pre-approve Jardiance tablets. You say that the enrollee is not able to take metformin. 
The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug. 
 
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 Jardiance tablets.  
 
Benefits for Jardiance tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device placement (22869, 
22870). 
 
You asked the Plan to pre-approve the interspinous spacer. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says this device is considered investigational and is not covered. 
 
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 interspinous spacer. Our reviewer 
says that the Vertiflex Superion Indirect Decompression System for implantation in this case is not medically 
reasonable and necessary. Our physician reviewer found current evidence based medical guidelines and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the 
use of this device for this enrollee's medical condition. 
 
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 interspinous spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer device placement (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for dental work. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 
a referral to an out-of-network provider for dental work.
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 do not feel that the SNF will be able to provide 
the appropriate level of therapy. The Plan denied your request. The Plan says IRF criteria have 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 the patient was admitted for COVID 19 and pneumonia. She was discharged to 
skilled nursing on 2/18/21 where she is receiving physical therapy services. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for syncope. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this will help from additional falls in the 
shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (J9271), Cisplatin (J9060), Irinotecan (J9206), 
Palonosetron (J2469), Dexamethasone (J1100), and Fosaprepitant IV (J1453). 
 
You asked the Plan to pre-approve Keytruda, Cisplatin, Irinotecan, Palonosetron, Dexamethasone, 
Fosaprepitant IV. You say that this service is medically necessary. The Plan denied your request. The Plan says 
that these drugs are not medically necessary and there is no compendia support. 
 
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, Cisplatin, Irinotecan, 
Palonosetron, Dexamethasone, Fosaprepitant IV. Our reviewer says that the requested drugs are medically 
necessary. Our physician reviewer found although these drugs are not approved by the FDA for the enrollee's 
diagnosis, the use is supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The requested drugs are safe and effective and otherwise reasonable and 
necessary for this enrollee's medical condition. 
 
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, Cisplatin, Irinotecan, Palonosetron, Dexamethasone, Fosaprepitant 
IV have been met. Therefore, we decided that the Plan has to pre-approve Keytruda (J9271), Cisplatin (J9060), 
Irinotecan (J9206), Palonosetron (J2469), Dexamethasone (J1100), and Fosaprepitant IV (J1453).  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of 
zoledronic acid or a history of osteoporosis-related fracture before they will approve the requested drug.  There 
is no evidence that the enrollee is allergic to or intolerant of zoledronic acid.  There is no evidence that the 
enrollee has tried and not responded to zoledronic acid and there is no documentation as to why these 
zoledronic acid would not be expected to be safe and effective for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 29, 2020 to July 31, 2020. 
 
You asked the Plan to pay for the services. You say that there was no payment on this claim. The Plan denied 
your request. The Plan says a corrected claim is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
A corrected claim is needed in this case. In this case, the plan pre-authorized the SNF stay provided that the 
PDPM (Patient-Driven Payment Model) score billed was KDSE. The SNF did not bill with this PDPM score 
and they have provided no explanation as to why they are billing with a PDPM score that is different than what 
was authorized. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) 
services provided to the enrollee from July 29, 2020 to July 31, 2020.
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 this is necessary to safely meet the 
enrollee's needs. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level 
of care. 
 
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 records show that the patient is more stable but requires additional short-term 
acute care services which can be safely administered at the current facility. The patient does not require 
services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH 
services will be considered not medically necessary at this time. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
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 a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee requires the height 
adjustment feature. The Plan denied your request. The Plan says the height adjustment feature is a convenience 
feature and is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee would be best served with SNF 
care to expedite her return home. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage of SNF 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee received physical therapy, occupational therapy, and 
speech therapy in the acute hospital. The enrollee was at a supervision to minimal assist level with functional 
mobility, including gait to 250 feet with a rolling walker. The enrollee required varying assist with activities of 
daily living. The enrollee was alert and oriented. There are identifiable skilled nursing service needs. There are 
not identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not 
meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.