Persius/hicric huggingface dataset:
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 able to tolerate 3 hours a day of 
intensive therapy. The Plan denied your request. The Plan says the enrollee is no longer demonstrating 
significant functional gains. 
 
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 is at a contact guard assist for grooming, minimal assist for sitting up and standing up, and 
contact guard assist for walking. The enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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 pre-approve an emergency alert system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee suffers from medical 
conditions that jeopardize her well-being if she is alone. The Plan denied your request. The Plan says the alert 
system is not for a medical problem. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an emergency alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested spinal decompression and fusion surgery. 
 
You asked the Plan to pre-approve the spinal surgery. You say that this surgery would benefit the enrollee's 
condition. The Plan denied your request. The Plan says the use of this procedure is not shown to be necessary 
for this patient. 
 
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 spinal surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found criteria for this revision surgery are not met. Imaging studies showing severe deformity and 
sagittal malalignment are not in the records. Also, there is no documented instability, failure of fusion, or 
severe neurological deficit documented in the records. Surgery is not needed 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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the requested spinal decompression and fusion surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent pens. 
 
You asked the Plan to pre-approve the Praluent pens. You say that this medication is necessary. The Plan 
denied your request. The Plan says this self-injected drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent pens.  
 
Benefits for the Praluent pens 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: 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. The Plan denied your request. The Plan says the enrollee is not 
medically complex, and does not require specialized therapeutic skills. 
 
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 pelvic fracture and T-12 compression fracture after a fall. His 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 he will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. The medical record supports a need for physical and occupational 
therapy, but 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 Tadalafil Tablet. 
 
You asked the Plan to pre-approve Tadalafil Tablet. You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered by the enrollee's Medicare Part B benefit. 
 
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 Tadalafil Tablet.  
 
Benefits for Tadalafil Tablet 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no daily skilled nurse or therapist need. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT Code 27447).
You asked the Plan to pre-approve the service. You say that the member has severe osteoarthritis of left knee. You state the member's mobility is quite compromised and the member is a candidate for a knee replacement surgery. The Plan denied your request. The Plan says that the service is 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 service. Our physician reviewer found this enrollee presented with progressively worsening left knee pain with giving way and buckling. Functional limitations were noted in mobility. Clinical exam findings were consistent with radiographic evidence of left knee end-stage osteoarthritis with complete loss of joint space laterally, osteophytes at joint margins in all 3 compartments, and subchondral sclerosis. the enrollee had failed long-term reasonable and/or comprehensive conservative treatment. The enrollee underwent left total knee arthroplasty on September 16, 2020 and required inpatient admission from September 16, 2020 through September 18, 2020. Under consideration is a request for inpatient total knee arthroplasty. This enrollee met all Medicare criteria as outlined above to support the medical necessity of left total knee replacement. The medical necessity of inpatient admission from September 16, 2020 to September 18, 2020 is also supported. The enrollee was unable to be discharged home on September 17, 2020 due to decreased functional mobility placing the enrollee at acute fall risk, inadequate pain management with oral medications necessitating the use of intravenous (IV) Dilaudid, and post-operative acute blood loss anemia requiring hemodynamic monitoring. Therefore, the enrollee had a diagnosis, condition, and/or symptoms that meets the Medicare criteria for coverage of left total knee replacement, and it was medically necessary for the enrollee to have inpatient total knee replacement.
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 service have been met. Therefore, we decided that the Plan has to pre-approve arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT Code 27447).
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: 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 this is medically necessary. The Plan 
denied your request. The Plan says there is no clinical advantage for LTACH over the acute hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include respiratory support with ventilator weaning, oxygen 
supplementation, nebulizer treatments, antibiotics, surveillance laboratory studies, electrolyte supplementation, 
NG tube, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia, 60 mg. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has side-effects from Fosamax. The Plan 
denied your request. The Plan says the requested drug was approved under Part D Medicare. The Plan also says 
that the drug was dispensed from a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia, 60 mg.
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 will require 3-4 more weeks 
of inpatient hospital care which would be best provided in an LTACH. The Plan denied your request. The Plan 
says the enrollee can receive all necessary care in the current facility. 
 
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 is a male with a history of prior COVID infection who presented to the 
acute hospital on 09/19/2020 with gastrointestinal bleeding and anemia. He was treated in the hospital with 
intravenous proton-pump inhibitor therapy, packed red cell transfusion and endoscopic epinephrine injection 
and cautery of a duodenal ulcer with a visible vessel, interventional radiology embolization and later an 
exploratory laparotomy for repair of the bleeding ulcer. He has also been treated for respiratory failure and 
pneumonia; he has a tracheostomy and is on total parenteral nutrition. He is on a T-piece with 21% aerosol 
with cuff deflated. Transfer to a long-term acute care hospital is requested. 
 
The short-term acute care hospital can provide for all the patient's present inpatient care needs and the patient 
is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care 
hospital is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient 
rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for Alpha-Stim/ Cranial Electrotherapy Stimulation Device provided on 
May 15, 2020. 
 
You asked the Plan to pay for the device. You say that the device is medically necessary. The Plan denied your 
request. The Plan says that the request for unproven technology does not meet CMS criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the device. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the physician documents that you have a nonresponsive condition that is significantly affecting 
your quality of life. There is evidence in the medical literature that suggests a modest benefit of cranial 
electrotherapy in patients with anxiety and depression.  
 
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 device have been met. Therefore, we decided that the Plan has to pay for 
Alpha-Stim/ Cranial Electrotherapy Stimulation Device provided on May 15, 2020.  
 
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: 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 the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no coverage for devices that will only be used outside of the home. 
 
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 the vehicle. Our reviewer says that the 
requested vehicle is not medically reasonable or necessary. Our physician reviewer found there is no evidence 
that your mobility deficit impairs participation in MRADLs in the home. Your deficit is currently helped by a 
cane. There has been in-person assessment in the home to evaluate that you could safely maneuver the vehicle 
in the home. 
 
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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
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 require rehab therapy and continuing wound 
care. The Plan denied your request. The Plan says your care is not complex, and do not need a team of 
providers for care. 
 
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 are at a minimal assist level for bed mobility, moderate assist for transfers and ambulation, and 
moderate assist for lower body dressing. You do not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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 Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says the enrollee is not 
using the drug for a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Reblozyl. Our physician reviewer found 
that the request is for Reblozyl to treat high risk myelodysplastic syndrome (MDS) with a chromosome 5 
deletion. The requested drug is indicated and supported in MDS with very low to intermediate risk MDS. 
The drug is not FDA-approved for the requested use. The use is not supported in any of the CMS approved 
compendia. There is no evidence of any supporting citations in a PubMed search. The use is not listed as not 
indicated, not recommended or not supported in any of the compendia. 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.