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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be safely met in a hospital setting, if approved by the plan. 
 
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 do not require the intensity of services provided at an IRF.  Specifically, you are 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose 
monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277) 
for the enrollee. 
 
You asked the Plan to pre-approve the sensor and transmitter. You say that the enrollee needs these items to 
monitor her blood glucose levels. The Plan denied your request. The Plan says that these items are not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies 
used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting 
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and 
supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial 
continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose 
monitoring (A9277) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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. Needs can be met in an alternate, 
less intense setting such as in a SNF. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole. 
 
You asked the Plan to pre-approve Esomeprazole. The Plan denied your request. The Plan says this is not 
covered under your Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esomeprazole.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not a candidate for traditional 
chemotherapy at this time. The Plan denied your request. The Plan says Keytruda alone for non-small cell lung 
cancer as a first treatment is not a medically accepted indication. 
 
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 physician reviewer 
found that Keytruda has been requested to treat metastatic non-small cell lung cancer (NSCLC) 
adenocarcinoma type, tumor mutational burden high, with negative PDL1, mismatch repair proteins proficient, 
who is too weak for Carboplatin and Alimta and doesn't want traditional chemotherapy. The requested use is 
not FDA approved. The requested use is not supported in any of the CMS approved compendia. 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 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your therapy needs did not appear to warrant 3 hours of therapy per day 
for 5 days a week. 
 
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. 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 at 
his current functional level and an interdisciplinary approach to rehab care. Your rehab needs can be met in an 
alternate, less intense setting such as in-home with services. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF 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-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute care 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. The patient appears to be improving gradually, however, requires additional short term acute care services (less than 25 days) for weaning and recovery which could be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) servicesfor the enrollee.
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 the enrollee is unable to care for himself and 
needs someone to assist him with moving, walking, toileting, and medication. The Plan denied your request. 
The Plan says the denial of authorization for SNF service is correct. 
 
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 does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While 
the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
Skilled Nursing Facility (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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipilimumab. 
 
You asked the Plan to pre-approve Ipilimumab. 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 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 Ipilimumab. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found 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 Ipilimumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ipilimumab.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. 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 were admitted for cervical laminectomy and 
fusion. Your medical problems are stable. There are no identified problems that need inpatient medical 
management. 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. 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 you will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer. 
 
You asked the Plan to pre-approve these services. You say that you have had back pain for two to three years. 
The Plan denied your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have chronic back pain. The requested interspinous spacer is considered experimental in nature, as more 
research is needed to its safety and effectiveness. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 and F5 genetic testing is not medically 
necessary. 
 
We looked at the file and Medicare rules. The requested services are F2 and F5 genetic testing. This testing is 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve F2 and F5 genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to durable medical 
equipment and supplies from preferred providers. 
 
We looked at the file and Medicare rules. The file shows that the Contour Next test strips are not from the 
Plan's preferred provider. Testing strips are available from the Plan's preferred provider. Therefore, we decided 
that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glumetza. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Glumetza.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI you had on January 27, 2020. 
 
You asked the Plan to waive the copayment. You say that you cannot afford to pay the copayment. The Plan 
denied your request. The Plan says you are responsible for the copayment. 
 
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 $175 
copayment for advanced imaging services.  
 
Review of the file shows that you had an MRI on January 27, 2020. You have been asked to pay a $175 
copayment for the MRI. The MRI falls within the advanced imaging services benefit category. 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 waive the copayment for the MRI you had on January 27, 2020.
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 needs pain control and rehab therapy to 
reach a baseline to go home. The Plan denied your request. The Plan says the enrollee does not require close 
medical supervision, or complex rehab needs that can only be met in an IRF. 
 
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 to the acute hospital for cervical spine surgery. Her 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. She 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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient physical therapy services. 
 
You asked the Plan to waive the copayments for these services. You say that the copayments are a financial 
hardship. The Plan denied your request. The Plan says the copayments cannot be waived. 
 
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 $30 
copayment for each Medicare-covered physical therapy and/or speech and language pathology visit.  
 
The services at issue are outpatient physical therapy visits. If you choose to receive these services, you will be 
asked to pay a $30 copayment per visit for these services. These services fall within the Medicare-covered 
physical therapy and/or speech and language pathology visit benefit category. This means that you will be 
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 waive the copayments for outpatient physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services you received on 
May 7, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $370 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
Review of the file shows that you were provided outpatient services on May 7, 2020. Per your contract with the 
Plan, there is a $370 copayment for these services. However, the Medicare allowed amount for these services is 
$52.36. As the allowed amount is less than the copayment, you have been asked to pay the lesser amount of 
$52.36 for the services. 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 waive the copayment for the outpatient services you 
received on May 7, 2020.