Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cardiomems system for the enrollee. 
 
You asked the Plan to pre-approve a Cardiomems system. You say that this is medically necessary. The Plan 
denied your request. The Plan says that a review of the current medical literature indicates that this service is 
considered experimental and 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 a Cardiomems system. Our reviewer 
says that a Cardiomems system is not considered medically reasonable and necessary in this case. In this 
circumstance 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. Moreover, 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. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for coverage of a Cardiomems system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Cardiomems system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cardiomems system for the enrollee.
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 enrollee requires extensive rehab 
therapies to regain strength and functional quality of life. The Plan denied your request. The Plan says the 
enrollee's medical conditions no longer require complex hospital 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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute 
renal dysfunction following recent trauma. The enrollee has a tracheotomy and feeding tube related to his prior 
hospitalization. The enrollee is not on a ventilator. There is no evidence that the enrollee requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. 
 
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection, 
chemotherapy administration, Granisetron Hydrochloride injection, and Azacitidine injection provided on May 
18, 2020. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injection, chemotherapy 
administration, Granisetron Hydrochloride injection, and Azacitidine injection. You say that the enrollee was 
enrolled in hospice, but terminated their hospice care on May 1, 2020. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 1, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the therapeutic, 
prophylactic, or diagnostic injection, chemotherapy administration, Granisetron Hydrochloride injection, and 
Azacitidine injection provided on May 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining 4 additional home health visits. 
 
You asked the Plan to pre-approve the remaining 4 additional home health visits. You say that the remaining 4 
additional home health visits are medically necessary. The Plan denied your request. The Plan says the 
remaining 4 additional home health visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 remaining 4 additional home health 
visits. Our reviewer says that the remaining 4 additional home health visits are not medically necessary. Our 
physician reviewer found the records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has had 
prior SN for disease and medication management and education. The enrollee's conditions are chronic, he is 
consuming all food and liquid by mouth, and there is no evidence of complex wound care or other SN need. 
The request for additional SN visits is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the remaining 4 additional home health visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the remaining 4 additional home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $35 specialist copayment and 20% coinsurance for 
services provided on July 14, 2020. 
 
You asked the Plan to waive this cost share. You say that your provider did not tell you there would be a copay. 
The Plan denied your request. The Plan says this cost share is a contractual obligation. The Plan states your 
provider submitted a claim and applied a $35.00 copay and $2.96 coinsurance for Medicare Part B drugs.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly states there is a copayment and 
coinsurance for this type of service. You have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the $35 specialist copayment and 20% coinsurance 
for services provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune Lua electrical stimulation device. 
 
You asked the Plan to pre-approve an Optune Lua electrical stimulation device. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested Optune Lua device. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of tumor treatment field therapy for any 
indications other than newly diagnosed Glioblastoma Multiforme will be denied as not reasonable and 
necessary.  
 
We looked at the file and Medicare rules. The file indicates that the Optune Lua is not being requested for the 
treatment of newly diagnosed Glioblastoma Multiforme. Therefore, we decided that the Plan does not have to 
pre-approve an Optune Lua electrical stimulation device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (atezolizumab) with Avastin (bevacizumab). 
 
You asked the Plan to pre-approve the requested drug regimen. You say that this treatment should be approved. 
The Plan denied your request. The Plan says the enrollee has had progression her cancer on another PD-L1 
agent. As such, use of another type is not supported. 
 
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 the requested drug regimen. Our 
reviewer says that the requested treatment is not considered medically reasonable and necessary. Our physician 
reviewer found the enrollee has left lung cancer with a history of surgery and chemoradiation, treated with 
carboplatin and Alimta. She had recurrence in 2018 which was treated with cisplatin and Alimta. A new 
recurrence in January 2020 was treated with pembrolizumab until August when she had progression of disease.  
 
Tecentriq is not FDA-approved for treatment of this cancer when there are been progression on another PD-L1 
therapy. This use is likewise not supported by any of the major drug compendia or clinical research in any 
CMS-approved journal. 
 
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 drug regimen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Tecentriq (atezolizumab) with Avastin (bevacizumab).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the left shoulder. 
 
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 CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee sustained a left rotator cuff 
injury. He was evaluated in January of 2020 and advised home exercises with anticipated resolution. In August 
of 2020, the enrollee reported recurrence of left shoulder pain. The enrollee had a diagnosis musculoskeletal 
ultrasound noted to have a partial tear. Documentation does not include plain film imaging, diagnostic 
differential, or anticipated plan of care pending the CT results. Without the support of the documentation, the 
CT scan is 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 computed tomography (CT) scan of the left shoulder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair. 
 
You asked the Plan to pre-approve the DME. You say that your current wheelchair is too big to navigate in the 
house. The Plan denied your request. The Plan says the replacement interval is less than 5 years and does not 
meet Medicare guidelines for the RUL for DME and they have not received any clinical information to support 
the need for a different mobility device. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. You were provided with a power 
wheelchair in December 2016. The requested additional clinical information from your doctor to support the 
request that a new power wheelchair is needed before the replacement interval has passed but we have not 
received any documentation from your doctor indicating you need a new power wheelchair. We will deny the 
request for a power wheelchair because the replacement interval is less than 5 years and does not meet 
Medicare guidelines for the RUL for DME and we have not received any clinical information to support the 
need for a different mobility device. Repairs to DME are generally covered regardless of the interval. 
Therefore, we decided that the Plan does not have to pre-approve the power wheelchair.
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 keep falling while in the hospital and need 
inpatient supervision before you can take care of yourself. The Plan denied your request. The Plan says the 
guidelines for coverage of IRF care 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 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 does 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 or can tolerate 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: 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 records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for an admission 
to a SNF. 
 
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 a course of IV antibiotics. The enrollee had stable vital signs, and uncomplicated wound care 
to several areas of pressure injury. The enrollee received physical therapy and occupational therapy in the acute 
hospital. The enrollee was dependent for functional mobility and activities of daily living. There are no 
identifiable skilled therapy service needs. There are identifiable skilled nursing 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 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pancreas transplant (48554). 
 
You asked the Plan to pre-approve a pancreas transplant. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that pancreas transplants alone (PA) are reasonable and 
necessary under limited circumstances. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a pancreas transplant. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found coverage criteria have not 
been met in this case, as the enrollee does not have type 1 diabetes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pancreas transplant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pancreas transplant (48554).
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 is receiving appropriate care at the current acute 
care facility. 
 
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 
appears to be improving but requires additional short term acute care services of less than 25 days to continue 
oxygen supplementation weaning and additional stabilization. The patient does not require services at the 
LTACH that are not already being provided at the current setting. 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 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 has a history of metastatic renal cell carcinoma with a malignant pleural effusion. She was admitted to 
the acute care hospital on 9/19/20 with acute dyspnea due to a right pleural effusion. The enrollee was 
intubated, and a chest tube was placed. The enrollee was weaned off the ventilator on 9/23/20. Antibiotics were 
started for a pneumonia in the right lower lobe. 
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. The member 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The documentation does not support that an additional 25 days 
of hospitalization are reasonably expected for the enrollee in this case. The clinical assessment in the case file 
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee 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.