Persius/hicric huggingface dataset:
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 you have serious cervical problems and one of 
the side effects is that you are losing your balance. You say that you have slipped several times in the shower 
and you are afraid that you may injure yourself in a fall. You stated that you live alone, and it is very risky for 
you to take a bath. You asked the Plan to reconsider their decision. 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: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not
met the step therapy requirements.
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 Gelsyn-3. Our reviewer says that the
enrollee has not met the step therapy requirements for coverage of Gelsyn-3. Our physician reviewer found that
based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no
indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) (0275T). 
 
You asked the Plan to pre-approve percutaneous image-guided lumbar decompression. You say that this is a 
covered benefit. The Plan denied your request. The Plan says this is only covered under a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD is covered through Coverage with 
Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee is enrolled in an approved 
clinical study for this procedure.Based on this information, we decided that Medicare rules for coverage of 
percutaneous image-guided lumbar decompression have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous image-guided lumbar decompression (PILD) (0275T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation supporting that services are required that cannot be 
provided at the current IRF. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of test is not covered by Medicare when it is being used to diagnose bacterial 
overgrowth. 
 
The Plan must follow Medicare rules. Medicare rules say that a lactulose breath hydrogen test to diagnose 
SIBO is not a covered benefit. 
 
The requested test is statutorily not covered. Based on this information, we decided that Medicare rules for 
coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
hydrogen breath test for the enrollee.
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 necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria 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 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 level 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral liquid nutrition.
You asked the Plan to pre-approve oral liquid nutrition. You say that the enrollee has persistent weight loss and
malnutrition. The Plan denied your request. The Plan says The Plan says enteral nutrition for oral intake is not
covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
Medicare rules say that enteral nutrition products administered orally are not covered.
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan
does not have to pre-approve oral liquid nutrition.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI of the neck for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a cogent review of the provided documentation did not provide an explanation for 
the request of the aforementioned study. 
 
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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the request for MRI of the 
neck is totally reasonable in light of history of neck mass and new onset of cough. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI of the neck for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found you were admitted to 
the acute inpatient psychiatric hospitalization on August 20, 2020 with Schizophrenia Spectrum Disorder. You 
did not present a dangerousness to yourself or others. You are showing some paranoia and auditory but no 
visual hallucinations and no aggressive behaviors. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health plan?s 
denial of inpatient psychiatric services appears appropriate. We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug in this case requires TMB high disease for first line treatment of metastatic anaplastic thyroid cancer.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab (Keytruda) is not FDA approved for anaplastic or poorly differentiated thyroid cancers. Use is not supported by major drug compendia or the medical literature. The enrollee has not been tested for MMR, MSI, or tumor mutational burden to support use base on molecular profiling of the tumor. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sock aid and dressing tool. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are not covered because they are considered convenience items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a sock aid and dressing tool.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care on 8/17/20 for evaluation and treatment of anion gap acidosis due to contraction ketosis. The enrollee is 
with known Alzheimer's dementia. From a nursing perspective, the enrollee received oral medications. The 
enrollee had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the enrollee received 
physical therapy in the acute hospital.  The enrollee was at a stand by assist to contact guard assist level with 
functional mobility including gait to 85 feet with a rolling walker. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda in combination with carboplatin and Taxol for the enrollee.
You asked the Plan to pre-approve Keytruda in combination with carboplatin and Taxol. You say that Keytruda in combination with carboplatin and Taxol is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 in combination with carboplatin and Taxol. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found this review relates to a request for Keytruda in combination with Carboplatin and Taxol for a 78-year-old woman with metastatic lung adenocarcinoma that is negative for molecular markers and PDL-1 expression 5-10%. She also has multiple myeloma, elevated creatinine and was performance status 2 at the office visit on August 20, 2020. Keytruda in the requested combination is not FDA approved. The requested use is not supported in any of the CMS compendia. This reviewer did not find any supporting citations in a PubMed search. The use is not listed as not indicated, not supported, or not recommended in any of the compendia. Medicare criteria are not met. 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 in combination with carboplatin and Taxol have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda in combination with carboplatin and Taxol for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care on 8/21/20 for increased falls and weakness. From a nursing perspective, the enrollee received oral 
medications. The enrollee had stable vital signs. Her lungs were clear. She used CPAP for sleep apnea. 
Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute 
hospital. The enrollee was at a stand by assist to contact guard assist level with functional mobility including 
gait to 50 feet with a rolling walker. She required varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift.
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 intensive therapy and daily monitoring in an IRF is 
medically necessary for wounds associated with a prosthesis. The Plan denied your request. The Plan says the 
enrollee's care does not need to be managed by a rehabilitation doctor. The Plan says that the enrollee's care 
does not require a nurse who has special training in rehabilitation. The Plan says that, at this time, the treatment 
plan goals could be safely achieved 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 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 requires this therapy to be on 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.