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

 
We decided that the Plan does not have to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. You say that there are multiple lesions that cannot be 
removed surgically. The Plan denied your request. The Plan says treatment with Atezolizumab is limited to 
patients with extensive stage small-cell lung cancer. 
 
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 Atezolizumab. Our physician reviewer 
found that the request is for Atezolizumab to treat recurrent, metastatic high grade, poorly differentiated 
neuroendocrine tumor of the pancreas, in combination with Carboplatin and Etoposide. Atezolizumab is not 
FDA-approved for the requested use. The drug is not supported in any of the approved compendia for the 
requested use. There is no mention of the use of this drug in the NCCN Guidelines for poorly differentiated 
neuroendocrine or small cell other than lung cancers. The use is not listed as not indicated, not supported or not 
recommended in any of the compendia. The documentation does not support that the requested drug is safe and 
effective, and otherwise 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 Atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Atezolizumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you need to check your blood sugar daily 
and that you can't use your standard machine because of muscular dystrophy. The Plan denied your request. 
The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met.  
 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is unfit to be at home. The Plan 
denied your request. The Plan says the enrollee does not require daily skilled nursing or rehab services. 
 
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 SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a supervision to 
contact guard assist level with functional mobility. Although there are identifiable skilled therapy service 
needs, the enrollee does not require skilled nursing or rehab services on a daily basis. The enrollee does not 
meet 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) 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 care can be received 
in another setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup and crown-porcelain/ceramic for tooth 
#12. 
 
You asked the Plan to pre-approve core buildup (D2950) and crown-porcelain/ceramic (D2740). You say that 
you need a crown on tooth #12. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve core 
buildup and crown-porcelain/ceramic for tooth #12.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical values of this device has not been established. 
 
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 the enrollee has a history of chronic kidney disease, defibrillator placement, obesity, 
hyperlipidemia, hypertension, coronary artery disease and NYSHA Class III congestive heart failure with 
reduced LV ejection fraction (LVEF 35%) requiring hospitalization. Therapy change based on data obtained 
from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission 
compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into 
question the results. 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. Medicare coverage 
criteria are not met since the device is still considered experimental/investigational. 
 
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 a CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 
78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer 
found the documentation does not clearly support that the enrollee meets diagnostic criteria for both 
Alzheimer's disease and Frontotemporal dementia, or that the cause of the enrollee's clinical symptoms remains 
uncertain. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 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 this patient appears to require additional short-term acute care services as they are 
improving, however, it is unlikely that they will require more than an additional twenty-five (25) days before 
stable enough to transfer. The patient does not require services at the LTACH that are not already available and 
covered at the current facility. There are no services at the LTACH that the patient 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. Transfer to a lower level of care may be considered soon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: 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 need rehab to regain your strength. The Plan 
denied your request. The Plan says that your nursing, medical management, and rehabilitation needs do not 
require an interdisciplinary team approach to delivery of 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and palpitations. 
Medications were adjusted. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF.  
 
The patient does not have complex wound care or other ongoing SNF level SN need. The patient's functional 
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. As a practical matter, this patient does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 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 this patient appears to require additional short-term acute care services as they are 
improving, however, it is unlikely that they will require more than an additional twenty-five (25) days. The 
patient does not require services at the LTACH that are not already available and covered at the current facility. 
There are no services at the LTACH that the patient 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. Transfer to a lower level of care may be considered soon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab. 
 
You asked the Plan to pre-approve Atezolizumab. You say that there are multiple lesions that cannot be 
removed surgically. The Plan denied your request. The Plan says the use of Atezolizumab is not covered for 
your condition 
 
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 Atezolizumab. Our physician reviewer 
found that the request is for Atezolizumab (Tecentriq) to treat recurrent, metastatic high grade, poorly 
differentiated neuroendocrine tumor of the pancreas, in combination with Carboplatin and Etoposide. 
Atezolizumab is not FDA-approved for the requested use. The drug is not supported in any of the CMS 
approved compendia for this use. There is no mention of the use of this drug in the NCCN Guidelines for 
poorly differentiated neuroendocrine or small cell other than lung cancers. The use is not listed as not indicated, 
not supported or not recommended in any of the compendia. The documentation does not support that the 
requested drug is safe and effective, and otherwise 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 Atezolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Atezolizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that 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 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 you appear to require additional short-term acute care services as they are improving, 
however, it is unlikely that they will require more than an additional twenty-five (25) days. You do not require 
services at the LTACH that are not already available and covered at the current facility. There are no services at 
the LTACH that you require 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. Transfer to a lower level 
of care may be considered soon when more stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: 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 member is receiving appropriate inpatient acute care and 
does not require transfer to LTACH. 
 
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 patient 
in this case appears to require additional acute care services for the short-term. The patient 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 patient requires that the current facility does not already have available and covered. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous left atrial appendage closure (LAAC), 
also known as the Watchman procedure. 
 
You asked the Plan to pre-approve the LAAC procedure. You say that this should be approved as it will benefit 
the enrollee. The Plan denied your request. The Plan says the enrollee is maintained on Xarelto with no issues 
related to long-term use. As such, the LAAC procedure is not reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC procedures may be covered for enrollees with 
atrial fibrillation who are not candidates for long-term oral anticoagulation therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LAAC procedure. Our reviewer 
says that the documentation does not support the medical necessity of the requested procedure. Our physician 
reviewer found based on the records, the patient has atrial fibrillation being treated with Xarelto with no 
documented bleeding complication and no documented contraindication to anticoagulation. In this 
circumstance, the records do not support the medical necessity for placement of a Watchman 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 LAAC procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous left atrial appendage closure (LAAC), also known as the 
Watchman procedure.