Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound/skin 
care, and daily therapy can be provided at a lower level of care. You are mostly MODERATE assist for 
functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for 
measurable gains to be attained within a reasonable and predicted period. 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that the records did not indicate that you have intense and complex care 
needs. 
 
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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, 
and daily therapy can be provided at a lower level of care. You are mostly standby assist for functional 
transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable 
gains to be attained within a reasonable, and predicted period. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not meet Medicare criteria for coverage. 
 
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. Our reviewer says that 
Keytruda is not medically reasonable and necessary in this case. The documentation indicates PDL1 testing is 
positive but does not include the results. No results of molecular testing for EGFR, ALK were submitted for 
review. The PD-L1 test result is not submitted for review and it is not determined whether it was an FDA 
approved test. There is insufficient information to determine whether the use meets FDA or compendium 
support. There are no supporting citations in a PubMed search. The NCCN compendium lists the drug as not 
supported/recommended/indicated. Our physician reviewer found that your condition does not meet Medicare 
criteria for coverage of Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ZEPZELCA 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 information provided does not show that the policy requirements have been met. 
 
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 the NCCN Guidelines 
Version 2.2020 do address small cell or neuroendocrine histology. There is no mention of the use of small cell 
lung cancer regimens and no mention of the use of ZEPZELCA. Therefore, the documentation does not support 
that the requested use is medically reasonable and necessary for the enrollee. The documentation does not 
support that the requested use is 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ZEPZELCA for the enrollee.
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. You say that the enrollee has decreased mobility and functioning. 
The Plan denied your request. The Plan says the enrollee's rehab needs are not complex, and does not require 
an interdisciplinary approach for 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 physician reviewer found 
that the enrollee presented to the acute hospital for a coronary artery bypass grafting (CABG) procedure. He is 
doing well and was extubated, weaning oxygen, gentle diuresis. Pain controlled and he neurologically stable. 
The enrollee is at minimal assist to contact guard assist for transfers, maximal assist for bed mobility, and 
moderate assist for upper and lower body dressing. 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. His medical status does not currently require intensive physician and nursing oversight only 
in an IRF. The enrollee may benefit from physical and occupational therapy, but the documentation does not 
support that her endurance level 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of 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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound/skin 
and catheter care, and daily therapy can be provided at a lower level of care. The member is mostly standby 
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will 
allow for measurable gains to be attained within a reasonable, and predicted period. Our physician reviewer 
found that the enrollee's 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 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on September 8, 2020 with weakness and shortness of breath. His condition has improved and he is 
working with physical and occupational therapy for weakness and deconditioning. He needs minimum 
assistance for walking with a rolling walker and contact to minimal assist for transfers and activities of daily 
living. He has no complex needs requiring an an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies haven't proven that Keytruda is helpful for treatment of the 
enrollee's health problem when used in combination with cyclophosphamide (Cytoxan) and bevacizumab 
(Avastin). 
 
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. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA-approved 
for the enrollee's diagnosis. Keytruda is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. The use of Keytruda is not listed as not indicated, 
not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 
does require physical therapy and occupational therapy services but based on the medical records provided the 
enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the 
enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery for all four quadrants. 
 
You asked the Plan to pre-approve the osseous surgery. You say that you feel that this is medically necessary 
due to your age and your medical conditions which would put you at risk for serious infection. The Plan denied 
your request. The Plan says this is not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the treatment of your teeth and the structures 
directly supporting your teeth. Although there may be medical concerns related to this requested procedure, the 
procedure itself falls within the definition of dental care which is excluded from Medicare coverage. Therefore, 
we decided that the Plan does not have to pre-approve osseous surgery for all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3410) and osseous, osteoperiosteal, or 
cartilage graft of the mandible or maxilla (D7950) provided on March 11, 2020. 
 
You asked the Plan to pay for the apicoectomy and osseous, osteoperiosteal, or cartilage graft. You say that 
these dental services were necessary. The Plan denied your request. The Plan says these services are not 
covered benefits under your dental plan. 
 
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 pay for the 
apicoectomy (D3410) and osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) 
provided on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Post-stabilization inpatient care provided November 12, 
2019 to November 14, 2019. 
 
You asked the Plan to pay for the Post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network 
hospital. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for the Post-stabilization inpatient care. Our 
reviewer says that coverage criteria was not met. Our physician reviewer found the enrollee was stable for safe 
repatriation to a Plan facility because her acute on chronic respiratory distress was identified, treated, and 
stabilized. The record did not show that the enrollee was unstable for transfer to a plan facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for Post-stabilization inpatient care provided November 12, 2019 to 
November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system implant device. 
 
You asked the Plan to pre-approve the CardioMEMS system implant device. You say that the enrollee's clinical 
needs and the scientific technology support the need for the requested device. You say that the CardioMEMS 
system implant is medically necessary. The Plan denied your request. The Plan says the requested device is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS system implant 
device. Our reviewer says that a CardioMEMS system implant device is not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee was stable as of July 9, 2020. The 
documentation in the case file is insufficient to demonstrate that the CardioMEMS system is medically 
reasonable and necessary for the enrollee in this case. The current medical evidence is insufficient to support 
the use of an implantable pulmonary artery pressure sensing device in patients with heart failure and a low 
injection fraction. Data on survival, long-term health benefits, safety, and quality of life are lacking. The 
American College of Cardiology and the American Heart Association have not specifically addressed 
outpatient wireless implantable pulmonary artery pressure monitoring. However, they state "There has been no 
established role for routine or periodic invasive hemodynamic measurements in the management of HF. Most 
drugs used for the treatment of HF are prescribed on the basis of their ability to improve symptoms or survival 
rather than their effect on hemodynamic variables. The initial and target doses of these drugs are generally 
selected on the basis of controlled trial experience rather than changes produced in cardiac output or pulmonary 
capillary wedge pressure." 
 
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 CardioMEMS system implant device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CardioMEMS system implant device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is being requested because the member 
would have to come in less times for treatment compared to Opdivo. The Plan denied your request. The Plan 
says that the enrollee does not meet requirements for coverage of Keytruda. 
 
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. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA-approved 
for the enrollee's diagnosis. The use of Keytruda is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. The use of Keytruda is not listed as not 
indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.