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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not able to treat your wounds yourself. 
The Plan denied your request. The Plan says you do not need daily skilled services on an inpatient basis. 
 
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 physician reviewer 
found that from a nursing perspective you received oral medications, your lungs were clear, and you received 
wound care. There are identifiable skilled nursing service needs. Regarding rehab services, you are bed bound 
at baseline, and dependent for care and mobility. There are no identifiable skilled therapy service needs. 
Although there are identifiable skilled nursing 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 skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is only covered 
for certain indications. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found you have a diagnosis of wedge compression fracture of first lumbar 
vertebra, initial encounter for closed fracture. The documentation does not support that the spine fracture is less 
than six weeks old. In addition, recent literature shows that kyphoplasty is not more effective than conservative 
measures for compression fractures. Therefore, you do not meet criteria for the requested 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 percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
has no acute symptoms that require 24-hour inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient services from September 7, 2020, were requested. 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 continued services. Our physician reviewer found that active treatment was 
not taking place. It did not appear that the services were reasonably expected to improve the enrollee's 
condition, or for the purpose of diagnosis. The records were supervised and evaluated by a physician. Based 
upon review the records provided, the enrollee was not shown to be a danger to herself or others. She was not 
showing any auditory or visual hallucinations, and was cooperative/compliant with treatment while not 
showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical non-spinal bone growth stimulator (BGS). 
 
You asked the Plan to pre-approve the BGS. You say that this should be approved. The Plan denied your 
request. The Plan says there is no evidence of a non-union in the documentation submitted. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone 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.  
 
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 BGS. Our reviewer says that the 
requested device is not medically reasonable and necessary. Our physician reviewer found he enrollee 
underwent a surgical procedure in March 2020 to the right foot. The notes do not include any recently 
performed physical examination or imaging to indicate the need for a bone growth stimulator. There is no 
documentation of failure of union of the osteotomy to qualify the request. There is no clinical rationale for the 
requested bone growth stimulator. The review has determined that the requested bone stimulator criteria are not 
met. The requested item is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the BGS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electrical non-spinal bone growth stimulator (BGS).
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. The Plan denied your request. The Plan says you have 
not completed the full course of care at the 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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include telemetry, intravenous cardiovascular drugs as indicated, surveillance laboratory studies, 
hemodialysis, close fluid balance, and therapy services. 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. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot appropriately rehab at a skilled 
nursing facility. The Plan denied your request. The Plan says the enrollee does not have complex medical or 
intensive rehab needs. 
 
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 was recently admitted with acute renal failure and cellulitis. Co-morbid conditions also include 
chronic systolic congestive heart failure and right knee pain. He is now non-toxic and afebrile. Hemodynamics 
are stable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He is at total assist for 
functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 24 additional routine transportation trips. You say that you are 
scheduled for knee surgery and have no way of getting to the facility. You say that you also need to get to 
follow-up appointments with your primary care physician and specialist. The Plan denied your request. The 
Plan says the number of routine transportation trips being requested are not covered under your contract. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way routine transportation trips per calendar year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition. 
 
You asked the Plan to pre-approve enteral nutrition. The Plan denied your request. The Plan says that it is not 
shown the enrollee has been unable to maintain weight, or unable to get enough energy from other foods or 
liquids. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Nutritional supplementation is not 
covered under Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve enteral 
nutrition.
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 requires aggressive therapy and close 
physician monitoring. The Plan denied your request. The Plan says the enrollee's medical care is not complex. 
 
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 suffered a fall. A left femoral neck fracture was diagnosed, and the enrollee underwent a hip 
hemiarthroplasty. The post-operative course has included pain management. Hemodynamics are now stable. 
The complexity of the enrollee's nursing, medical, and rehab needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The enrollee is at maximal assist for functional 
transfers and activities of daily living. The enrollee does not  require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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. You say that waiting could jeopardize the enrollee's 
health and ability to regain maximum function. You say that based on the enrollee's medical needs she is stable 
and suitable for transfer to an LTACH. The Plan denied your request. The Plan says the criteria for LTACH 
care has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require any services at the LTACH that are not already 
available 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symbicort. 
 
You asked the Plan to pre-approve Symbicort. You say that the enrollee has been on Symbicort in the past with 
a great outcome. The Plan denied your request. The Plan says this drug is not covered by the Part B plan for the 
enrollee's condition. 
 
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 Symbicort.  
 
Benefits for Symbicort 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous closure of the left atrial appendage. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee's score are below the required threshold, and there is no documented contraindication to long-term 
anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules say that a percutaneous left atrial appendage closure is only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of PAF and a CHA2DS2-VASc score of 2. Per Medicare 
coverage rules, a score of 3 or more is required for consideration of Watchman therapy. In addition, based on 
the medical notes the enrollee does not have a significant clinical contraindication to warfarin, Eliquis, or other 
anti-coagulation medications other than cost issues. By report, he had been on warfarin in the past but was 
switched to DOACs as he did not want to get INRs checked.  His Has-Bled score is only 1, making him a 
reasonable candidate for anti-coagulation. His ulcer is not active and he has not had bleeding issues while on 
his current anti-coagulation regimen of Eliquis. Because he has no current clinical contraindication to long-
term anti-coagulation, he does not meet the coverage criteria for the Watchman 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous closure of the left atrial appendage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve these services. You say that you have already established care with this 
provider. The Plan denied your request. The Plan says the services are available from 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 neurosurgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Invokana. 
 
You asked the Plan to pre-approve Invokana. The Plan denied your request. The Plan says this drug is not 
covered under the enrollee's Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana.
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 continued physician oversight and an 
interdisciplinary team are indicated. The Plan denied your request. The Plan says the enrollee does not need to 
be seen three times a week by a rehab physician. 
 
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 was admitted for diverticulitis and hip fracture. All medical problems are stable. The 
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation 
that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. While the record supports a need for physical and occupational therapy, it does not support 
a need for an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab and Fulvestrant. 
 
You asked the Plan to pre-approve Pembrolizumab and Fulvestrant. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested drugs are 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 Pembrolizumab and Fulvestrant. Our 
reviewer says that the documentation does not support that the requested drugs are medically reasonable or 
necessary. Our physician reviewer found the enrollee has endometrial cancer. The documentation does not 
support that the requested use of Pembrolizumab and Fulvestrant is FDA-approved for the enrollee's diagnosis. 
The documentation does not support that these two drugs together are supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee 
does not meet criteria for the requested drugs. 
 
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 Fulvestrant have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Pembrolizumab and Fulvestrant.