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

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. 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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has complaints of 
grade 7 out of 10 left-sided low back and left lower extremity pain, Signs and symptoms are reported consistent 
with neurogenic claudication. There is imaging evidence of L4/5 moderate to severe central canal stenosis and 
bilateral lateral recess stenosis, and moderate to severe left and mild right neuroforaminal narrowing.  
 
There is also imaging evidence of moderate to severe neuroforaminal narrowing at the L3/4 and L5/S1 levels. 
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 
condition as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in enrollees with moderate stenosis in whom operative treatment is indicated at no more 
than two levels, from L1 to L5. This enrollee has moderate to severe spinal stenosis at the L3/4, L4/5, and 
L5/S1 levels which does not meet FDA indications for 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 insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-level referral for a barium swallow study. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this can be safely done at an in-network non-tertiary level provider. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found your modified barium swallow with esophogram can be performed with a non-tertiary level provider. 
This is a common test that is ordered to evaluate patients who suffer from dysphagia. You do not need to be 
referred for a tertiary level center for this test. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary-level referral for a barium swallow study.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary for treatment of the 
enrollee's condition. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for 
coverage of the requested drug. 
 
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 Neulasta. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the use of Neulasta is FDA-approved for the 
enrollee's diagnosis since the enrollee has more than a 20% risk of neutropenic fever based on the regimen with 
age and renal insufficiency. The enrollee is being treated with curative intent. Our physician reviewer found 
that the documentation supports that the requested drug is safe, effective, 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 Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing home health visits (G0299, G0300). 
 
You asked the Plan to pre-approve home health  visits. You say that the enrollee needs skilled nursing services. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 skilled nursing home health visits 
(G0299, G0300). Our reviewer says that the enrollee does not meet criteria for home healthcare. Our physician 
reviewer found the enrollee is not homebound, as indicated on her home health recertification form and by her 
attendance to a recent in-office doctor's appointment.  The enrollee does not have documented skilled nursing 
needs. 
 
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  visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing home health visits (G0299, G0300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer procedure. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
procedure. The Plan denied your request. The Plan says this procedure is not shown to be safe and effective. 
 
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 Superion procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. 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 the Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Superion interspinous spacer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve power operated vehicle. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for this device is correct, because the documentation 
does not indicate that the enrollee is unable to use a manual wheelchair, or that there is enough room in the 
enrollee's home to safely use a power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power operated vehicle. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested power operated vehicle. Our 
physician reviewer found the documentation does reveal that the enrollee has a personal mobility deficit, but 
the documentation does not clearly reveal that the enrollee's mobility deficit is unable to be helped by a manual 
wheelchair or walker. The documentation reveals no assessment of the enrollee's home to evaluate that she can 
safely maneuver this power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power operated vehicle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is with PDL1 
negative non-small cell lung cancer compressing her esophagus. Previous treatment included an investigational 
anti-PD1 monoclonal antibody. The requested use of Keytruda is not FDA approved. The requested use of 
Keytruda is not supported in any of the CMS approved compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 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. 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 was admitted to the current acute care hospital with loss of 
consciousness and left occipital lobe cerebrovascular accident. The course was complicated by acute 
respiratory failure, acute kidney injury, pneumonia, anemia, encephalopathy, and malnutrition. The enrollee 
requires ventilator weaning. The documentation does not support that the enrollee requires services at the 
LTACH that are not already available at the current setting. There are no services at the LTACH that the 
enrollee requires that the patient requires that are not already available and covered at 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: 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 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 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 based on review of the medical records, the enrollee does not meet the CMS 
coverage criteria for an IRF admission based on lack of medical and nursing needs and current functional 
status. She is medically stable with Debility from a recent hypertensive emergency. There is no documented 
evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care at the current functional status. The enrollee's rehab needs can be met 
in an alternate, less intense setting such as in a skilled nursing facility (SNF) or in-home with 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TKA, right knee. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found the medical records indicate that the patient's body mass index (BMI) is too high to meet established 
criteria for the surgery. The patient must lose weight prior to surgery. Criteria not yet 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TKA, right knee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you 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 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 treated in the hospital for compression fractures of the L3 and L4 
vertebrae with zoledronic acid and analgesics. The enrollee was able to walk 15 feet with no assistive device. 
The enrollee required moderate assistance for transfers and activities of daily living. The documentation does 
not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee 
required an intensive rehabilitation therapy program. The enrollee's care needs can be met at 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a suspension sleeve (L2397), straight knee joint (L2385), soft 
interfaces (L2820 and L2830) provided on March 31, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because the supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include a shipping/billing invoice to indicate the specific supplies or a proof of delivery for 
the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include a billing/shipping invoice to verify the supplies billed or a proof of delivery ticket for 
the billed date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a suspension 
sleeve (L2397), straight knee joint (L2385), soft interfaces (L2820 and L2830) provided on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula provided on January 6, 2020. 
 
You asked the Plan to pay for enteral formula. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says a signed delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include a signed delivery by the enrollee. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for enteral formula provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
documentation does not support that the complexity of your nursing, medical and rehabilitation needs requires 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation 
does not support that you require acute rehab nursing care, or monitoring by an inpatient physical medicine and 
rehab physician three times per week. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fentanyl citrate injection coded J3010 provided on 
August 6, 2019. 
 
You asked the Plan to pay for the fentanyl citrate injection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J3010 is injection, fentanyl citrate, 0.1 mg. 
 
We find that CPT code J3010 is not supported in the medical record. Specifically, the procedure note indicates 
that compounded drug was administered. Therefore, there is a more appropriate code that should be used to bill 
the services provided. Based on this information, we decided that Medicare rules for coverage of the fentanyl 
citrate injection have not been met. Therefore, we decided that the Plan does not have to pay for the fentanyl 
citrate injection coded J3010 provided on August 6, 2019.