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

 
We decided that the Plan does not have to pre-approve the Dexcom G6 continuous glucose monitor (HCPCS 
A9276, A9277, A9278). 
 
You asked the Plan to pre-approve the monitor. You say that this is the latest device and the easiest to work 
with. The Plan denied your request. The Plan says the request is for a non-therapeutic monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are covered when 
they are FDA-approved and considered therapeutic.  
 
 
 
 
 
 
 
The requested monitor is considered non-therapeutic. Based on this information, we decided that Medicare 
rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Dexcom G6 continuous glucose monitor (HCPCS A9276, A9277, A9278).
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 SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required maximum 
assistance with self-feeding. The enrollee was total dependent with grooming, upper and lower body dressing, 
and toileting. The enrollee's speech therapist recommends a mechanical soft, nectar thick liquid diet. The 
documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a 
skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, at a SNF level of 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 SNF 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
August 14, 2020. 
 
You asked the Plan to pre-approve the SNF care. You say that continued care in the SNF is necessary. The Plan 
denied your request. The Plan says you require less than daily wound care and do not require daily skilled 
therapy. 
 
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 care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the patient is an 87-year-old male who 
was admitted to SNF on 7/29/20 diagnoses of cellulitis, acute kidney injury, and severe peripheral vascular 
disease. He is unable to ambulate and requires use of Hoyer for transfers. He needs max assist for wheelchair 
mobility, toileting and lower body bathing and dressing.  
 
The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF beyond the last covered date. He does not have complex wound care or other ongoing SN 
need beyond the last covered date. His wounds and Foley care are chronic. He does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF beyond the last covered date. He does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" beyond 
the last covered date. As a practical matter, this patient does not require the necessary services on an inpatient 
basis, in a skilled nursing facility setting beyond the last covered date. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) care beyond August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services. 
 
You asked the Plan to pre-approve the core buildup services. The Plan denied your request. The Plan says this 
is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. The plan covers only those dental services listed in the Evidence of Coverage. 
Core buildup services are not covered. Therefore, we decided that the Plan does not have to pre-approve core 
buildup services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says inpatient 
admission 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 inpatient admission. Our reviewer says 
that the requested inpatient admission is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was approved for observation care which would have been sufficient 
in this case, as there was no complex care or monitoring needed for more than 2 days. Monitoring for 
improvements with the treatment started in the ED could have been completed under observation status. 
Therefore, this request for inpatient services will be considered not medically necessary based on the provided 
documentation. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine patches. 
 
You asked the Plan to pre-approve Buprenorphine. You say that no other treatment will be as effective at this 
time. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
Medicare Part B. 
 
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 Buprenorphine patches.  
 
Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine tablets. 
 
You asked the Plan to pre-approve the Cyclobenzaprine tablets. You say that this medication has been 
prescribed as a post-operative medication to be taken after surgery. You also say that your post-operative pain 
management protocol includes Cyclobenzaprine to limit the use of opioids after surgery. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
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 Cyclobenzaprine tablets.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary to properly stage the 
enrollee for the new diagnosis of high-risk prostate cancer. The Plan denied your request. The Plan says this is 
not medically supported at this time. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found per the nccn guidelines 
prostate ca 2.2020 page PROS for high risk prostate cancer, pelvic and abdominal imaging is recommended, 
but not CT scan of the chest. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the thorax for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purple 3 Hybrid Premier mattress.
You asked the Plan to pre-approve the mattress. The Plan denied your request. The Plan says this is not necessary.
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 Purple 3 Hybrid Premier mattress.
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 is facing being discharged from the 
current facility. You also say that the enrollee is still using supplemental oxygen, and would benefit from 
therapy education. The Plan denied your request. The Plan says Medicare coverage criteria have not been met 
for admission to an acute IRF. 
 
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 records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Our reviewer also found that the enrollee is mostly 
moderate and minimal assist for functional transfers, 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.  
An IRF intensity is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current 
level of 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary care.
 
You asked the Plan to pre-approve tertiary care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are 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 tertiary care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you were diagnosed atypical papillary lesion involving the left breast. You were treated with a 
left breast lumpectomy. You were interested in participating in a clinical trial, however, you did not qualify for 
the trial. Based on the provided documentation, the planned partial breast irradiation therapy could be safely 
and effectively be completed by a non-tertiary as you will not be participating in the clinical trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tertiary care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tertiary care.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
coverage of LTACH 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found additional acute care services appear to be needed. However, the enrollee appears to 
be near her baseline and is stable. The enrollee should not require at least an additional 25 days of acute care. 
Transfer to home with home services, or a skilled nursing facility to provide needs (including therapy) appears 
to be most appropriate at this time. There are no services available at the LTACH which are not already being 
provided and covered in the current 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that the records provided support the need for the requested drug. The Plan denied your request. The Plan says the use of the requested drug to treat shoulder osteoarthritis is not supported.
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 Zilretta. Our reviewer says that the drug in dispute is not medically necessary. Our physician reviewer found Zilretta is experimental for the treatment of shoulder degenerative joint disease. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy. 
 
You asked the Plan to pre-approve endovenous ablation. You say that you have pain in your leg when standing 
and use a girdle to support your leg, but it does not help. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because you do not meet the body-mass index criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy may be covered for 
enrollees who meet the clinical criteria listed 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 endovenous ablation. Our reviewer says 
that you do not meet the Medicare criteria for this service. Our physician reviewer found there is insufficient 
documentation that you are having significant symptoms attributable to your venous reflux that are refractory 
to conservative treatment. You do not meet body-mass index coverage criteria. The treatment mode being 
requested is not one of those approved by the Plan, because there is less documentation of the long-term 
efficacy of this treatment method. The documentation does not meet coverage criteria and does not support 
medical necessity of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab 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 treating physician requested this therapy, but did not provide relevant clinical 
information to support medical necessity. 
 
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 requested use of 
Keytruda is not FDA approved nor is it supported in any of the CMS approved compendia. Therefore the the 
documentation does not support that the Pembrolizumab is medically reasonable and necessary for the enrollee. 
The documentation does not support that the Pembrolizumab 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 Pembrolizumab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there is 
no clinical advantage of a LTACH over an acute hospital. 
 
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 enrollee does not require services at the LTACH that are not already available at 
the current facility. There are not services available at the LTACH that the enrollee requires that are not 
available and covered at the current facility. Our physician reviewer also found that this request for LTACH 
services does not appear to be warranted based on the documentation provided and will be considered not 
medically necessary 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 LTACH services.