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

 
We decided that the Plan has to pre-approve Computed Tomography (CT) of the Chest (71260). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria is not met. 
 
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 the CT scan. Our reviewer says that the 
CT scan is medically necessary. Our physician reviewer found the CT scan will yield meaningful information 
regarding whether an invasive biopsy procedure needs to be performed. The CT scan is 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve Computed Tomography (CT) of the Chest (71260).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for non-medical transportation to doctor?s visits. 
 
You asked the Plan to provide coverage for the non-medical transportation to doctor?s visits. You say that you 
need transportation to your doctor?s visits. The Plan denied your request. The Plan says you have used all of 
your transportation benefits. 
 
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 40 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have exhausted 
the routine transportation benefit for the 2020 calendar year. Therefore, we decided that the Plan does not have 
to provide coverage for non-medical transportation to doctor?s visits.
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 SNF services. You say that SNF services are 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 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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee's condition 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-
approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's 
nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require 
intensive physician and nursing oversight only in an IRF. The documentation does not support that the 
enrollee's functional status 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 for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a cardiac pacemaker. 
 
You asked the Plan to pre-approve a cardiac pacemaker. You say that the requested cardiac pacemaker is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested cardiac pacemaker. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a cardiac pacemaker. Our reviewer says 
that the enrollee meets criteria for the requested cardiac pacemaker. Our physician reviewer found based on the 
records the enrollee has a baseline trifascicular block on ECG, sudden syncope and a telemetry strip 
demonstrating an episode of complete heart block and greater than 4 second pause.  In this circumstance the 
documentation supports the medical necessity for pacemaker placement.  Coverage criteria are met since the 
enrollee has "Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block." 
 
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 cardiac pacemaker have been met. Therefore, we decided that the Plan has to 
pre-approve a cardiac pacemaker.  
 
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: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan has to pre-approve acute inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that inpatient admission is 
medically necessary. The Plan denied your request. The Plan says that 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 psychiatric hospital services. 
Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found you have auditory 
hallucinations. Active treatment is taking place. Inpatient services are reasonably expected to improve the 
current condition. The records are supervised and evaluated by a physician. You are not shown to be a danger 
to yourself or others however you are noncompliant with treatment. Medicare criteria for coverage are 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve acute inpatient psychiatric hospitalization.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (G0297). 
 
You asked the Plan to pre-approve a LDCT scan for lung cancer screening. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee is a non-smoker. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a LDCT scan is covered when specific criteria 
are met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a LDCT scan for lung cancer screening have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening 
(G0297).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent (J3590). 
 
You asked the Plan to pre-approve Praluent. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent (J3590).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq and bevacizumab treatment. 
 
You asked the Plan to pre-approve the Tecentriq/bevacizumab regimen. You say that the requested medication 
is medically necessary. The Plan denied your request. The Plan says the enrollee has already received first-line 
therapy with lenvatnib. The Plan says that the criteria for coverage have not been 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 the Tecentriq/bevacizumab regimen. 
Our reviewer says that the requested treatment regimen is not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has hepatocellular carcinoma with disease progression on 
lenvatinib. FDA approval for Tecentriq is for the treatment of unresectable or metastatic hepatocellular 
carcinoma (in combination with bevacizumab) in patients who have not received prior systemic therapy. The 
major drug compendia and CMS-approved medical journals do not support this regimen and other 
immunotherapy regimens are available for use as second-line therapy. 
 
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 Tecentriq/bevacizumab regimen have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Tecentriq and bevacizumab treatment.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve behavioral health services with an out-of-network provider. 
 
You asked the Plan to pre-approve behavioral health services. You say that you were not satisfied with the 
services you received with the in-network behavioral health group. You say that you are resistant to 
antidepressants and you would like to explore other treatments available for you besides medication. The Plan 
denied your request. The Plan says that you must receive services from an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We looked at the file and Medicare rules. The file shows that you are resistant to antidepressants and you are 
looking to explore other treatment methods besides medication. The Plan redirected you to the in-network 
behavioral health group, to which you have already been seen by without success.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. In this case, the Plan has confirmed that there are no other in-
network behavioral health providers available to you that you have not already seen. Furthermore, the Plan did 
not confirm if the in-network provider offered any alternative treatment to medication for your needs. Based on 
this information, we decided that Medicare rules for coverage of behavioral health services have been met. 
Therefore, we decided that the Plan has to pre-approve behavioral health services with an out-of-network 
provider.  
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) device.You asked the Plan to pre-approvea CGM device. You say that the item is necessary.The Plan denied your request. The Plan says you do not use insulin. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM device have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) device.
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 clinical documentation provided 
supports the request for LTACH care. The Plan denied your request. The Plan says guidelines for coverage of 
LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is a 75 year old male who was admitted to the current acute care hospital 
with COVID-19 pneumonia, respiratory failure, and septic shock. He was treated with antibiotics, remdesevir, 
steroids, high flow oxygen, and BiPAP. The course was complicated by acute kidney injury. Recent notes 
suggest the patient is improving overall. 
 
The patient appears to be improving but additional short term acute care services (likely less than 25 days) are 
still needed to further stabilize, which can be completed in the current setting. The patient does not require 
services at the LTACH that are not already available at the current setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the medication is 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 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 Retacrit. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the Retacrit is safe and effective for the enrollee as adequate iron stores have not 
been documented. Transferrin saturation should be 20% and ferritin 100 mcg/L for use of Retacrit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health nursing services. The Plan denied your request. The Plan says 
there is no evidence of infection, and the skin is intact. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The documentation shows that 14 home health skilled nursing visits were requested. The Plan has agreed to 
pre-approve 10 visits. 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 additional home 
health nursing services. Our physician reviewer found that you have been receiving home health services for 
chronic diabetic wounds. There are no acute issues noted. The additional four visits are not shown to be 
medically necessary or reasonable. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health nursing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health skilled nursing visits.