Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for peripheral artery disease and had an above the knee amputation on the right. The patient is being treated with intravenous antibiotics until December 9, 2020, for an infection ofan arterial graft. Medical problems are otherwise stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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-approveacute 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. The Plan denied your request. The Plan says you are unlikely able 
to meaningfully participate in 3 hours of therapy a day. 
 
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 were admitted to the acute hospital for heart failure, and had a mitral valve replacement. Your medical 
problems are stable. The complexity of your 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 you 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the eye exam provided on August 6, 
2020. 
 
You asked the Plan to reduce the cost sharing for the eye exam. You say that you were asked to pay a $20 
copayment at the time of the visit and this should be sufficient. The Plan denied your request. The Plan says the 
correct copayment for this visit was $40. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for eye exams to treat diseases and conditions of the eye.  
 
You have been asked to pay a $40 copayment for the eye exam. This exam was performed in the presence of an 
artificial ocular lens from cataract surgery and with early stage macular degeneration. As such, the exam falls 
into the medical eye exam category, not routine. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost sharing for 
the eye exam provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the supply allowance for a therapeutic continuous 
glucose monitor (K0553). 
 
You asked the Plan to pre-approve the supply allowance. You say that you would like reconsideration because 
these supplies are medically necessary. The Plan denied your request. The Plan says these supplies were denied 
because you have end stage renal disease and are on dialysis. 
 
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 supply allowance. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the fluid shifts and other factors in patients on hemodialysis may make the data from 
a continuous glucose monitor unreliable and are hence not recommended nor FDA approved. 
 
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 supply allowance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the supply allowance for a therapeutic continuous glucose monitor (K0553).
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 patient appears to be requiring additional short term acute care services which can 
safely be performed at the current facility and is not yet stable for transfer. The patient does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that are 
not already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer may be considered when treatment has completed and 
the patient is more stable. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs assistance with 
activities of daily living and personal care. The Plan denied your request. The Plan says the enrollee is not 
receiving any skilled nursing or therapy services in the home. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file, and Medicare rules. Custodial care is not covered by Medicare or the enrollee's plan. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says additional 
services are not medically necessary. 
 
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 additional services. Our physician 
reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy 
for the enrollee's condition. The enrollee has had extensive therapy for this condition. It does not appear that 
her functional level requires the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The  
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 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 additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional occupational therapy 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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is 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 patient appears to be improving, however, additional short term acute care 
services is required and can safely be performed at the current facility. The patient does not require services at 
the LTACH that are not already available at the current facility. There are no services at the LTACH that are 
not already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered when 
treatment has completed. 
 
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 pay for the acute inpatient hospital care provided on February 4, 
2020, through February 5, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the 
enrollee did not need to be admitted inpatient in order to get the care needed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the member's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 4, 2020, through February 
5, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve radiation therapy for prostate adenocarcinoma (CPT Codes:
77295, 77300, 55876, G6002).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says that there is no current research showing that the enrollee's type of cancer responds
better to the requested type of treatment than the type of treatment the Plan can approve. The Plan states this
type of treatment is called Intensity Modulated Radiation Therapy (IMRT) and it uses beams of intense energy
to kill or shrink cancer cells. The Plan states this is done by targeting the disease site and this treatment would
be approved if requested.
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 pre-approve the services. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an
accepted treatment approach. To date, there are no compelling data to suggest that proton therapy is superior to
or more beneficial than IMRT/IGRT but is an accepted treatment. This LCD (L35075) allows for coverage
proton therapy for prostate cancer if: 1. There is physician documentation of patient selection criteria (stage and
other factors) and this is provided in the consult note. 2. Documentation and verification that the patient was
informed of the range of therapy choices, including risks and benefits and this is provided in the consult note.
And per the LCD, coverage is "limited to providers who have demonstrated experience in data collection and
analysis with a history of publication on the peer-reviewed medical literature."
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 been met. Therefore, we decided that the Plan has to preapprove
radiation therapy for prostate adenocarcinoma (CPT Codes: 77295, 77300, 55876, G6002).
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aquatic therapy services provided. 
 
You asked the Plan to pay for the aquatic therapy services. You say that these services were medically 
necessary and should be covered. The Plan denied your request. The Plan says there is no evidence that the 
enrollee was not able to do land-based physical therapy. As such, aquatic therapy is not considered 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 pay for the aquatic therapy services. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal objective measurable deficits on a physical exam 
that supports that the patient requires the unique skills of a professional therapist to safely and effectively 
provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. It is unclear how many prior land based and water based therapy sessions that patient 
has had or why the patient is unable to participate in a land based therapy program. The document 
does not reveal that the patient required the skills of a professional therapist. The specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the patient'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 the aquatic therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the aquatic therapy services provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Alclometasone Dipro. 
 
You asked the Plan to pre-approve Alclometasone Dipro. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Alclometasone Dipro.  
 
Benefits for Alclometasone Dipro 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care to 
return to her independent living. The Plan denied your request. The Plan says the enrollee does not require 
extensive wound care management, or daily intervention by a physician. 
 
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 the enrollee was admitted to the current acute care hospital with COPD exacerbation, 
pneumonia, and sepsis. She was treated with vasopressors, mechanical ventilation, steroids, antivirals, 
antifungals, and antibiotics. The course was complicated by esophagitis, weakness, and anemia. Trach and PEG 
were placed. She has recently been weaned to trach collar successfully. The records show that the enrollee has 
been improving, but requires additional short-term acute care services, which can safely be performed in the 
current facility. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Therefore, this request for LTACH services will be considered 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 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 KADCYLA (ado-trastuzumab). 
 
You asked the Plan to pre-approve the KADCYLA treatments. You say that this treatment should be allowed. 
The Plan denied your request. The Plan says there is no evidence to support the use of KADCYLA in this case. 
 
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 the KADCYLA treatments. Our 
reviewer says that the requested treatment is not considered reasonable and necessary in this case. Our 
physician reviewer found this review relates to a request for KADCYLA to treat a 73-year-old woman with 
uterine cancer that is HER2 positive and has progressed on Herceptin based treatment. KADCYLA is not FDA 
approved for uterine cancer. KADCYLA is not supported in any of the CMS approved compendia. The 
prescriber submitted a single case report from 2016.  This reviewer did not find any supportive citations in a 
PubMed search. Case reports are not considered acceptable by CMS to determine medically accepted use. 
 
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 KADCYLA treatments have not been met. Therefore, we decided that the 
Plan does not have to pre-approve KADCYLA (ado-trastuzumab).