Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to walk unassisted. The Plan 
denied your request. The Plan says you do not need daily skilled therapy in an inpatient facility. 
 
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 that from a nursing perspective, you 
received oral medications, had stable vital signs, and were treated for a urinary tract infection. There are no 
identifiable skilled nursing service needs. Regarding rehab services, you are at a supervision to contact guard 
assist level with functional mobility. You require varying assist with activities of daily living. Although there 
are identifiable skilled therapy service needs, you do not require skilled nursing or skilled therapy on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee does not meet the hospital level 
of stay, but needs additional rehabilitation at a sub-acute facility. You say that the enrollee needs to be able to 
walk more independently and be more independent with toileting and lower body dressing. You say that the 
enrollee would be discharging home alone and does not have the funds to hire a care giver or to go into assisted 
living. You say that the enrollee is very high stay risk and is unable to manage his medication and finances on 
his own. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been 
met. The Plan says that, with additional time in the rehabilitation hospital, the enrollee may be ready to receive 
services in an outpatient setting or at home. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for right knee pain. The enrollee's lungs were clear. The 
enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a 
supervision to independent level with functional mobility, including gait to 160 feet.  
 
 
The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. 
The 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: 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 ready to go to the next step of therapy. 
The Plan denied your request. The Plan says the enrollee does not requires intensive, complex interdisciplinary 
therapy in the acute inpatient 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 physician reviewer found 
that the enrollee's current level of function is standby assist for ambulation, moderate assist for upper and lower 
body bathing, and minimal assist for dressing. The enrollee is currently medically stable with debility from a 
respiratory illness. There is no evidence of complex medical issues that require monitoring by an inpatient 
rehabilitation physician three times per week, or acute rehab nursing care. While he may benefit from 
continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program 
with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service can be safely provided in-network by participating providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network dialysis provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pan management services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are 
providers within your network that can treat pain. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve pan 
management services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab-awwb (Mvasi). 
 
You asked the Plan to pre-approve Mvasi. You say that this is the third line for chemotherapy. The Plan denied 
your request. The Plan says the drug is used in combination with fluoropyrimidine based chemotherapy for first 
or second-line therapy, or in combination with fluoropyrimidine irinotecan or fluoropyrimidine-oxaliplatin 
based chemotherapy for second-line therapy. 
 
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 Mvasi. Our physician reviewer found 
that the enrollee has stage IV sigmoid colon cancer. He was treated with FOLFOX and Avastin with 
improvement. A computed tomography (CT) scan in August 2020, showed some liver mets have increased. 
The requested use of Mvasi is not FDA-approved for the enrollee's diagnosis as monotherapy for fourth line 
therapy. The requested use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The documentation does not support that the requested drug is 
safe and effective and otherwise reasonable and necessary for this 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 Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve bevacizumab-awwb (Mvasi).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ampyra Tab 10mg. 
 
You asked the Plan to pre-approve Ampyra Tab 10mg. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Ampyra Tab 10mg.  
 
Benefits for Ampyra Tab 10mg 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (77399). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the NCCN Guidelines Version 6.2020 Non-small cell lung cancer page NSCL-C 1 of 
10 discusses types of radiation for safe delivery of curative radiation. These include proton beam among other 
types of treatment including 4D-CT and/or PET/CT simulation, IMRT (intensity modulated radiation) VMAT 
(volumetric modulated arc therapy), IGRT (image guided radiation), and motion management. It states IMRT 
is preferred over 3D-CRT (conformal radiation). The guidelines do not state a preference for proton beam 
therapy. Therefore, IMRT, which is approved by the plan, is within the guidelines. Proton beam therapy is not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is receiving the appropriate care in the Inpatient 
Rehabilitation Facility. 
 
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's condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 mental health treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the 
criteria for continued acute inpatient mental health treatment for the dates in question of August 28, 2020 
forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or 
visual hallucinations and she was cooperative/compliant with treatment. 
 
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 treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone gel for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under 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 Testosterone gel for the 
enrollee.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide this care. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99215) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan of the head (78814). 
 
You asked the Plan to pre-approve a PET CT scan of the head. 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. Medicare rules say that PET 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 a PET CT scan of the head. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found per CMS guidelines 
PET/CT of the brain is indicated using FDG-18 when there is a differential diagnosis of FTD vs. Alzhemier 
dementia. This differential does not apply to this enrollee per the clinical chart. Also, CMS will allow one PET 
scan of the brain for Amyloid but only if the enrollee is in a qualified clinical trial however there is no such 
indication in this individual. 
 
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 PET CT scan of the head have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan of the head (78814).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator for the enrollee. 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that there was no documentation of two 
images 90 days apart stating that there has been no clinically significant evidence of fracture healing. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had 
ceased. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator 
for the enrollee.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the CT of the abdomen. We decided that the Plan does not have to 
pre-approve the CT of the pelvis.  
 
You asked the Plan to pre-approve a CT of the abdomen and a CT of the pelvis. You say that the requested CT 
scans are needed for the doctors to assess your health care needs. You say that the CT scan in dispute will 
allow the doctors to determine whether the cancer has returned.  The Plan says that the clinical information 
provided describes a condition that supports imaging a different body region than the one requested. 
 
We decided that the Plan has to pre-approve the CT of the abdomen. 
 
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 for a CT of the abdomen. Our reviewer says that a CT 
of the abdomen is medically necessary. Our physician reviewer found that the enrollee received a diagnosis of 
renal cancer in December of 2019. The standard medical guidelines recommend an abdominal CT for stage II 
or III every 3-6 months for 3 years. Our physician reviewer found that the enrollee's situation calls for a CT of 
the abdomen. 
 
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 CT of the abdomen have been met. 
 
Therefore, we decided that the Plan has to pre-approve a CT of the abdomen.  
 
We also decided that the Plan does not have to pre-approve the CT of the pelvis. 
 
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 for the CT of the pelvis. Our physician reviewer says 
that a CT of the pelvis is not medically necessary. Our physician reviewer found that the documentation 
provided did not show why a CT of the pelvis was necessary for the enrollee's treatment.  
 
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 CT of the pelvis have not been met. 
 
Therefore, we decided that the Plan does not have to pre-approve a CT scan of the pelvis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp 200 Mcg/0.4 ml Syringe for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered by the 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 Aranesp 200 Mcg/0.4 ml 
Syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick urine collection system. 
 
You asked the Plan to pre-approve a Purewick urine collection system. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick urine collection 
system.