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 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
peripheral artery disease and had a right below the knee amputation. Medical conditions are stable. There are 
no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. 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. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that other providers have refused to operate on you, 
but this provider advised you that he can safely remove your tumor. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan 
and you can be treated by an in-network specialist. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #20. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service has a 
limit to two in a calendar year. The Plan also says that the enrollee's history plus this request has gone over this 
limit. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to 2 per 1 calendar 
year(s). The record shows that the enrollee received crowns on tooth #'s 24 and 25 on November 10, 2020, and 
the enrollee's crowns benefit had been exhausted for the 2020 Plan year. Therefore, we decided that the Plan 
does not have to pre-approve a crown (D2750) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2751) for tooth number 18. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that your request exceeds the allowable benefit for this 
item. 
 
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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plan contract states that a crown is covered once per 
tooth, per sixty (60) months. You previously received a crown for tooth number 18 on February 1, 2017, less 
than sixty months ago. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown 
(D2751) for tooth number 18.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 clinical information provided supports that the 
enrollee is ready for transfer to acute rehab. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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. The patient was 
admitted for weakness and falls. The enrollee's medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that the enrollee 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-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 a knee scooter/walker or crutch substitute (E0118 
Crutch substitute lower leg platform, with or without wheels). 
 
You asked the Plan to pre-approve a knee scooter/walker. You say that you broke your ankle and the knee 
scooter would be helpful. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter/walker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter/walker or crutch substitute (E0118 Crutch substitute lower leg platform, with or without 
wheels).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider. 
 
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 
the medical services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for low back pain and had kyphoplasty for compression fracture 
of L1 vertebra. Your medical conditions are stable. The documentation does not support that you require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation 
does support a need for physical therapy and occupational therapy, the documentation does not support that you 
require 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 Mvasi and Tecentriq. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the 
regimen is only supported as a first-line therapy. 
 
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 requested drugs. Our physician 
reviewer found that the requested use of the drug regimen is not FDA-approved for your diagnosis. Tecentriq is 
FDA approved for the treatment of unresectable or metastatic hepatocellular carcinoma in those who have not 
received prior systemic therapy. You have had at least 2 prior lines of therapy. The use is not supported by one 
of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. The use 
is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation 
does not support that the requested drug is safe and effective, and otherwise 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 requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Mvasi and Tecentriq.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve 8 cycles of Trodelvy. 
 
You asked the Plan to pre-approve the 8 cycles of Trodelvy. You say that the drug in dispute is medically 
necessary and that your life is on the line. The Plan denied your request. The Plan says that an exception to 
FDA regulations, and due to delay for 2 months, they have approved 2 cycles. The Plan says that the 10 cycles 
requested 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 the 8 cycles of Trodelvy. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found while the use of Trodelvy is 
not FDA approved for the enrollee's diagnosis, as she has not had more than or equal to 2 prior systemic lines 
of therapy for metastatic triple negative breast cancer, the use is supported by clinical research that appears in a 
CMS-approved medical journal. Specifically, Bardia A, Tolaney SM, Loirat D, Punie K, Oliveira M, Rugo HS, 
Brufsky A, Kalinsky K, Cort's J, O'Shaughnessy J, Dieras VC. LBA17 ASCENT: A randomized phase III 
study of sacituzumab govitecan (SG) vs treatment of physician?s choice (TPC) in patients (pts) with previously 
treated metastatic triple-negative breast cancer (mTNBC). Annals of Oncology. 2020 Sep 1;31:S1149-50. The 
requested drug is not listed as not indicated, not supported, or not recommended in any of the compendia. Our 
physician reviewer found that the documentation supports 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 the 8 cycles of Trodelvy have been met. Therefore, we decided that the Plan has 
to pre-approve 8 cycles of Trodelvy.  
 
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 foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this will allow your continuous walking exercise and help with improper balance and pain. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. 
The enrollee had stable vital signs. The enrollee required set-up/clean up assistance level with functional 
mobility including walking with home health aide. The enrollee required varying assistance with activities of 
daily living. The documentation does not support that the enrollee requires the specialized skills, knowledge, or 
judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically 
necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy 
services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services 
on an inpatient basis, at a SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OneTouch Ultra Blue Test Strips. 
 
You asked the Plan to pre-approve the OneTouch Ultra Blue Test strips. You say that you would like a 
reconsideration. The Plan denied your request. The Plan says the are plan preferred alternatives available. 
 
The Plan must follow Medicare rules. Medicare rules say that the benefit provides coverage for the requested 
product when medically necessary. However, the information submitted doesnt meet the plan medical 
necessity guidelines for coverage. The member must meet the following criteria: a non-preferred meter and test 
strips for self-monitoring of blood sugar (i.e. fingerstick testing) is said to be medically necessary for the 
member by a healthcare provider. The plan's preferred meters and test strips include: meters and test strips 
marketed by Roche (e.g. Accu-Chek Aviva Plus, Accu-Chek Guide, Accu-Chek Guide Me) or Trividia Health 
(e.g. TrueMetrix, TrueTrack). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OneTouch Ultra Blue Test strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the OneTouch Ultra Blue Test Strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for release and/or relocation of median nerve of hand (64721) 
incision of tendon covering (26055). 
 
You asked the Plan to pay for release and/or relocation of median nerve of hand. You say that you have been 
doing the splints for over a year and you wouldn't mind doing the splints as requested for the denial if you 
weren't already doing the splints. The Plan denied your request. The Plan says this request was not medically 
necessary for the enrollee's medical 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 pay for release and/or relocation of median nerve of 
hand. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is limited documentation of any significant trial and 
failure of conservative care modalities (specifically splinting, activity modification and/or injection) provided 
for review. Literature/peer review studies do not support this request without prior failure of conservative 
treatment. Exceptional indications are not evident. Therefore, the request for release and/or relocation of 
median nerve of hand 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 release and/or relocation of median nerve of hand have not been met. Therefore, 
we decided that the Plan does not have to pay for release and/or relocation of median nerve of hand (64721) 
incision of tendon covering (26055).