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

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care. The Plan denied your request. The Plan says 
the enrollee is medically stable, and her care does not warrant inpatient care. 
 
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 pre-approve acute inpatient hospital care. Our 
physician reviewer found that the enrollee presented to the hospital for an elective, scheduled L3-L4 
laminectomy, with medial facetectomy and foraminotomy. There were no intra-operative complications or 
post-operative concerns noted in the record. The enrollee was noted to be ambulatory 200 feet with a rollator. 
The enrollee reported left eye vision changes that predated her presentation to the hospital, and she was advised 
to follow-up with ophthalmology as an outpatient. The care plan included expectant post-operative 
management. The procedure is not on the inpatient-only list. The care provided to the enrollee was observation 
level. There were no advance interventions or complex medical conditions. Therefore, inpatient services were 
not supported by the documentation. 
 
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 pre-approve an inpatient hospital admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET scan. Our physician reviewer 
found the presence of adenopathy without pathologic diagnosis or even without high suspicion of malignancy 
based on findings on imaging study does not warrant a PET scan. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization 
imaging; skull base to mid-thigh (CPT Code 78815).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that several clinical papers have been 
published on the reliability, accuracy, and ease of use of this testing device, and this testing is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because studies have not proven that this test is helpful for the evaluation of the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bioimpedance spectroscopy is not considered a standard of care for the 
assessment of lymphedema. The enrollee is documented as having improvement with physical therapy and 
compression sleeve. The request is for prevention according to the documentation provided. Bioimpedance 
spectroscopy is helpful in detecting sub-clinical disease but this enrollee has known lymphedema and is already 
being treated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 doses of Revlimid, 5mg. 
 
You asked the Plan to pre-approve Revlimid. You say that the regimen was approved for 3 months. You also 
say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested 
drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part 
D prescription drug plan. The Plan says the requested drug is not covered under Medicare Part B. The Plan also 
says there is no non-self-administered equivalent. 
 
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 7 doses of Revlimid, 5mg.  
 
Benefits for Revlimid 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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on review of the 
medical records, the enrollee does not meet criteria for an IRF admission. She is generally medically stable 
with debility from COVID-19 PNA with no evidence of medical or nursing needs for an IRF and her current 
functional status does not require IRF level of therapies. There is no 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is very shaky and needs gait 
training. The Plan denied your request. The Plan says the enrollee is medically stable, and his needs are 
custodial. 
 
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, the enrollee received oral medications, had stable vital signs, and had 
urinary retention, which was resolved. There are no identifiable skilled nursing service needs. Regarding rehab 
services, the enrollee is at a contact guard to minimal assist level with functional mobility. He required varying 
assist with activities of daily living. Although there are identifiable skilled therapy service needs, he does not 
require skilled nursing or therapy services on a daily basis. The enrollee does 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Laparoscopic Sleeve Gastrectomy. 
 
You asked the Plan to pre-approve Laparoscopic Sleeve Gastrectomy. You say that the requested Laparoscopic 
Sleeve Gastrectomy is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the requested Laparoscopic Sleeve Gastrectomy. 
 
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 Laparoscopic Sleeve Gastrectomy. Our 
reviewer says that the enrollee does not meet criteria for the requested Laparoscopic Sleeve Gastrectomy. Our 
physician reviewer found the enrollee is with obesity; on 9/21/20, her BMI was 44.7. The enrollee has not 
responded to conservative management. The documentation does not support that the enrollee has at least one 
of the following serious comorbidities: diabetes mellitus, hypertension, hyperlipidemia, joint disease requiring 
surgical intervention, gastroesophageal reflux disease that is refractory to a 2 month trial of appropriate 
treatment and medications, obstructive sleep apnea requiring CPAP, or potential organ transplant candidacy at 
a UNOS-certified center whereby a BMI of 35 or more is required. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Laparoscopic Sleeve Gastrectomy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Laparoscopic Sleeve Gastrectomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 550mg Tablets of Xifaxan. 
 
You asked the Plan to pre-approve the Xifxan. You say that you would like reconsideration because the Xifxan 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for your condition 
by Medicare Part B or the 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 550mg Tablets of Xifaxan.  
 
Benefits for the Xifxan 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 units of Keytruda, 100 mg. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee pursued an alternative therapy option 
which resulted in progression of the enrollee's disease. You also say that you would like the enrollee to start a 
new therapy treatment as soon as possible to prevent further progression. The Plan denied your request. The 
Plan says the documentation supports the diagnosis of advanced non-small cell lung cancer. The Plan says the 
enrollee has a PD-L1 score of less than 1%. The Plan also says coverage cannot be authorized at this time. 
 
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 drug does not meet the criteria for coverage. Our physician reviewer found the supported use of the 
drug in this setting requires that the tumor have positive PDL-1 of less than or equal to 1%. The reviewer found 
that the requested use of the drug is not approved by the FDA. The reviewer found the use is not listed as not 
indicated, not supported, not recommended in any of the compendia. Therefore, the requested drug does not 
meet the criteria for coverage. 
 
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 36 units of Keytruda, 100 mg.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the right shoulder. 
 
You asked the Plan to pre-approve an MRI of the right shoulder. You say that the requested MRI of the right 
shoulder is medically necessary. The Plan denied your request. The Plan says the requested MRI of the right 
shoulder is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the right shoulder. Our 
reviewer says that the requested MRI of the right shoulder is not medically necessary. Our physician reviewer 
found the enrollee is with atraumatic bilateral shoulder pain (worse on right). The medical records do not show 
a trial and failure of conservative measures to include physical therapy. More conservative measures are 
needed. The requested MRI 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 an MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the right shoulder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNorthera.You asked the Plan to pre-approveNorthera. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered 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-approveNorthera.Benefits for Northeramay be available under Medicare Part D.Contactthe 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 Transthoracic Echocardiogram (TTE) and a Stress 
Transthoracic Echocardiogram (Stress TTE). 
 
You asked the Plan to pre-approve a Transthoracic Echocardiogram (TTE) and a Stress Transthoracic 
Echocardiogram (Stress TTE). You say that the requested Transthoracic Echocardiogram (TTE) and Stress 
Transthoracic Echocardiogram (Stress TTE) are medically necessary. The Plan denied your request. The Plan 
says the requested Transthoracic Echocardiogram (TTE) and Stress Transthoracic Echocardiogram (Stress 
TTE) 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 Transthoracic Echocardiogram (TTE) 
and Stress Transthoracic Echocardiogram (Stress TTE). Our reviewer says that the requested Transthoracic 
Echocardiogram (TTE) and Stress Transthoracic Echocardiogram (Stress TTE) are not medically necessary. 
Our physician reviewer found based on the record the enrollee had recent stent placement 06/18/2019, no 
subsequent chest pain and no "new symptoms".  In this circumstance of a clinically stable patient less than 2 
years from prior coronary revascularization the medical necessity for repeat stress testing or transthoracic 
echocardiogram is not supported by the records not by current clinical practice guidelines. Coverage criteria is 
not 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 Transthoracic Echocardiogram (TTE) and Stress Transthoracic Echocardiogram 
(Stress TTE) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Transthoracic Echocardiogram (TTE) and a Stress Transthoracic Echocardiogram (Stress TTE).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified oral surgery, and drug dispensed in 
office for home use. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services 
are not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified oral surgery, and drug dispensed in office for home use.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve block procedure (64450). 
 
You asked the Plan to pre-approve the nerve block procedure. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says the requested procedure is not medically necessary and 
is not proven effective for this use. 
 
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 nerve block procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the effectiveness of Genicular nerve blocks to treat knee pain has not been 
established. Genicular nerve blocks are considered experimental/investigational in nature. As such, Genicular 
nerve block to treat knee pain is not medically 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 the nerve block procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve block procedure (64450).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc Injections (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the Synvisc injections are medically necessary. The 
Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be 
considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
injections are not medically necessary. Our physician reviewer found the record does not show a trial of the 
plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for the 
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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc Injections (J7325).