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

 
We decided that the Plan does not have to pre-approve pembrolizumab (J9271) and Alimta (J9305). 
 
You asked the Plan to pre-approve pembrolizumab and Alimta. You say that the medications 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 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 pembrolizumab and Alimta. Our 
reviewer says that the medications are not medically necessary. Our physician reviewer found pemetrexed 
(Alimta) and pembrolizumab are used as maintenance therapy for non-small cell lung cancer after treatment 
with carboplatin/pemetrexed/pembrolizumab. There is no documentation provided showing that the enrollee 
received prior therapy with the combination and carboplatin. Therefore, the service is not reasonable or 
medically 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 pembrolizumab and Alimta have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pembrolizumab (J9271) and Alimta (J9305).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for 
decompression (MILD procedure). 
 
You asked the Plan to pre-approve MILD procedure. You say that this procedure is medically necessary for the 
enrollee and should be covered. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because studies have not proven that this procedure is helpful for the enrollee's condition. 
 
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 MILD procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MILD procedure is experimental. More research is needed to show its 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 MILD procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve percutaneous laminotomy/laminectomy for decompression (MILD procedure).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac join injections. 
 
You asked the Plan to pre-approve the sacroiliac join injections . You say that you would like reconsideration 
because the member has sacrolitis and ongoing symptoms. The Plan denied your request. The Plan says this 
service 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 sacroiliac join injections  
. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the medical records do not document that the enrollee has the diagnosis 
of Sacroiliitis.  The prescriber did not provide any recent medical records to substantiate the diagnosis of 
sacroiliitis. 
 
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 sacroiliac join injections  
 have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac join injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that the doctor told you that you would need a 
Rollacart to avoid your putting your foot down and messing up the screws. You say that a wheelchair would be 
too hard to get to the bathroom and get around the house with. You say that your doctor advised you would 
need the Rollator Cart for around three months, until you are healed. The Plan denied your request. The Plan 
says crutch substitutes have not been proven to be medically necessary and are not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare has determined that platform crutches will be denied as not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute 
(E0118).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy
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 plan requires the use of in-network 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 physical therapy provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care.
The Plan denied your request. The Plan says the guidelines for coverage of IRF care. The Plan says that the
enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was admitted to the hospital on August 14, 2020 with worsening
weakness and falls. The enrollee had weakness and had been feeling weak for months. The enrollee's CHF is
well-compensated and her diabetes is well-controlled. The enrollee is on BiPAP at night. The enrollee is in no
acute distress. A physical therapy report on August 17, 2020 recommended physical therapy 3-5 times per
week. The complexity of the enrollee's nursing, medication and rehabilitation needs do not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally
medically stable and the documentation does not support that she has complex medical issues that require acute
rehab nursing care or monitoring by an inpatient physical medicine and rehabilitation physician three times per
week. While the enrollee is reasonably expected to benefit from physical therapy and occupational therapy, the
documentation does not support that there is a 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: 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 you are a fall risk due to weakness. The Plan denied 
your request. The Plan says there is no medical complexity to support the need for a rehab physician 3 times a 
week. 
 
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 you have a history of small-cell lung cancer, which is metastatic to bone and brain. It is documented that 
you were chair bound and unable to wheel yourself. You have severe generalized weakness. Your prognosis 
and rehab potential are noted to be guarded. The complexity of your nursing, medical and rehabilitation needs 
do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block. 
 
You asked the Plan to pre-approve a lumbar/sacral facet joint block. 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 follows Medicare rules. Medicare rules say that injections may be repeated if the first injection results 
in significant pain relief (>50%) for at least 3 months. 
 
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 lumbar/sacral facet joint block. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found according to the 
documentation, this enrollee has low back pain with radicular pain.  The facet joint injections are limited to 
patients with low-back pain that is non-radicular. Medicare does not cover this procedure when there is 
evidence of radiculopathy. The requested facet joint injection is not medically 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 a lumbar/sacral facet joint block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar/sacral facet joint block.
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 medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with respiratory failure, emphysema, and pneumonia. She was transferred from 
LTACH where she was weaning from ventilation following a COVID-19 infection, but was found 
unresponsive. She was treated with antibiotics, a chest tube, steroids, and mechanical ventilation. She required 
PEG placement. She has since improved enough to tolerate weaning trials and is progressing well on a T piece. 
The enrollee does not require services at the proposed LTACH that are not already available at the current 
facility. There are no services available at the proposed LTACH that the enrollee requires that are not already 
available and covered at the current facility. The LTACH services are therefore not reasonable or medically 
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 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: 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 these 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 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, skin care, and 
daily therapy can be provided at a lower level of care. It is not clear the member would be able to fully benefit 
and/or participate in an IRF level of care. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a re-evaluation of physical therapy (PT) established plan 
of care and 10 additional PT visits. 
 
You asked the Plan to pre-approve a re-evaluation of PT established plan of care and 10 additional PT visits. 
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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 re-evaluation of PT established plan 
of care and 10 additional PT visits. Our reviewer says that skilled services are not necessary to restore or 
maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the 
requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The 
enrollee has had extensive prior therapy and the records do not indicate his functional level which is near 
baseline requires the unique skills of a professional therapist to safely and effectively provide treatment. 
Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a 
therapist. The enrollee has been educated in safety, body mechanics, and therapeutic activities. The requested 
services are not part of a maintenance program and the specialized skill, knowledge and judgment of a 
qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
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 re-evaluation of PT established plan of care and 10 additional PT visits have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a re-evaluation of physical 
therapy (PT) established plan of care and 10 additional PT visits.
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 your therapy needs can be provided at a lower level.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were treated for a fracture of the lower leg. An external fixation device has been placed. All medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While there is documentation of a need for physical and occupational therapy, the documentation does not support a need for intensive rehabilitation services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
records do not show that the enrollee needs things that cannot be done at a lower level of care, or the enrollee 
did not get better at a lower 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 enrollee does not require services at the proposed LTACH that are not already 
available at the current facility. Our reviewer found that there are no services available at the proposed LTACH 
that the enrollee requires that are not already available and covered at the current facility. Our physician 
reviewer also found that this request for LTACH services will be considered not medically necessary. 
Continued acute care services can be received appropriately at the current setting until stable enough for 
discharge to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 the enrollee would be better served at the LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 requires services at the LTACH that are not already available at the current acute care hospital. The clinical progression suggests that although additional acute care is needed for a short while longer, it is unlikely that more than 24 days of acute care services will be needed. Transfer to a lower 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 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.