Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says there is no compendia support for the requested drug to treat the 
enrollee's condition. 
 
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 Enhertu. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with metastatic HER2neg (1+) breast cancer and has been treated with fam-trastuzumab + 
bevacizumab (Mvasi). In this case, the requested use of Enhertu is not FDA-approved for the enrollees 
diagnosis as the tumor is not HER2+ and there are no prior lines of HER2 based therapy. Furthermore, the use 
of Enhertu is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS). 
 
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 not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PNS is covered for specific indications only. 
 
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 enrollee has right shoulder pain 
after a stroke. He has tried medication trials, exercise, heat, and rest. He has psychological clearance for PNS 
placement. The use of a PNS for shoulder pain after a stroke is not supported by the medical literature. The 
services are 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 peripheral nerve stimulation (PNS).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve home health services. You say that home health services are medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 home health 
services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on 
the medical record documentation provided, the enrollee does not have documented skilled nursing needs. 
There are no medication needs, wound care, or ostomy training needs. Medicare coverage criteria for home 
health care are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve peripheral nerve stimulation (PNS). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PNS is covered when specific criteria are met. 
 
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 medically necessary. Our physician reviewer found the enrollee has chronic low back and 
buttock pain. He had a trial of physical therapy and takes Tylenol, Advil, and Tramadol for pain. He had a 
diagnostic cluneal nerve block on November 8, 2021 that produced 100 percent pain relief. The criteria for 
coverage are met and PNS of the right cluneal nerve is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve peripheral nerve stimulation (PNS).  
 
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 pay for supply allowance for therapeutic CGM, includes all supplies 
and accessories, 1 month supply = 1 unit of service (CPT code K0553) provided on August 9, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The ordering provider has denied ordering the denied item. In addition, the submitted documentation submitted 
did not sufficiently support the billed supply code. Based on this information, we decided that Medicare rules 
for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for 
supply allowance for therapeutic CGM, includes all supplies and accessories, 1 month supply = 1 unit of 
service (CPT code K0553) provided on August 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 17, 2021, 
and billed under code 23929. 
 
You asked the Plan to pay for these services. You say that this claim should be paid.  The Plan denied your 
request. The Plan says the records provided do not support the services billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We asked our coder 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 
these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the provider 
reported code 23929 which is defined as an unlisted procedure shoulder in addition to other services performed 
on same date of service. The operative report does not support an unlisted procedure. An unlisted procedure 
should only be reported when no other procedure code exists. Documentation should specify what procedure is 
being reported with an unlisted procedure code.  In this case, the unlisted procedure code reported is not 
supported in the records. Medicare billing criteria are not met.  
 
 We looked at this coder'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 pay for physician services provided to the enrollee on June 17, 2021, and billed under code 23929.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 in the Medicare rules section. 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 nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You were admitted for weakness, congestive heart failure, and multiple myeloma. Medical problems are stable. 
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 patient has a need for physical and/or occupational therapy, there is no documentation of 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous LAAC for non-valvular atrial fibrillation 
device. 
 
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this device. 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 this device.  Our physician reviewer found at issue is the medical necessity of implanting a LAAC device in a clinical 
situation where there is elevated risk of thromboembolic stroke due to atrial fibrillation and a high 
CHADS2VASC score. However, according to your physician you do not have a contraindication to 
anticoagulation medications. As such, the guidelines would not support implantation of a LAAC in this case.  
Medicare coverage criteria are 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 this device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous LAAC for non-valvular atrial fibrillation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested 
LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee was admitted to the hospital with COVID pneumonia complicated by bacteremia and was treated 
with antibiotics and BiPAP, intubation, and vasopressors. The course was complicated by hemorrhagic shock, 
anemia, transaminitis, diarrhea, and oral thrush. The enrollee appears to be more stable and improving and 
should only require short-term additional acute care hospital services that can safely be administered at the 
current facility until appropriate for a lower level of care. The patient does not require services at the LTACH 
that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would 
not be clinically advantageous. Medicare coverage criteria are 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 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 for the enrollee.
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 based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 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 surgical management of a femur fracture. Medical problems are stable. 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. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation 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-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve home health services. You say that home health care is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 home health 
services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the 
documentation does not show you require additional skilled nursing services to provide treatment that is 
medically necessary. You do not require additional skilled nursing services to effectively provide treatment, 
care, and/or services in order to improve the current condition, perform a maintenance program to maintain 
your current condition and/or prevent deterioration. You are medically stable without any recent exacerbations 
of chronic medical problems or hospitalizations.  The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says the required step therapy criteria are not met. 
 
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 Simponi Aria. Our 
reviewer says that the required criteria are not met. Our physician reviewer found you have psoriatic 
arthropathy, collagenous colitis, and rheumatoid arthritis. It was reported that she had tried and failed Otezla, 
sulfasalazine, and Plaquenil in the past. The Otezla helped the psoriasis rash but not the joint pain/swelling. 
Humira had been offered in the past but declined. There was no indication Humira would have been 
contraindicated or not appropriate now. The provided records did not clearly show evidence of the patient 
having tried and failed Enbrel, Humira, Rinvoq, or Xeljanz/Xeljanz XR. The above preferred agents would not 
likely be less effective or cause more side effects than the requested Simponi Aria as they are in the same drug 
class and comparative studies show similar effectiveness and safety data between them in the setting of 
treatment for the patient's condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria.
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 the SNF admission. You say that you feel that you require care in the SNF 
setting. The Plan denied your request. The Plan says daily skilled services are not medically necessary in this 
case. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the member is a 90-yr-old female 
with a medical history including atrial fibrillation on warfarin, hypertension and peripheral artery disease who 
was admitted to the hospital after a mechanical fall at home resulting in a hematoma and pelvic fracture. She 
was treated for hypokalemia and has been medically stabilized. The most recent therapy documentation 
indicates the member isn't able to participate meaningfully with skilled therapy due to her cognitive issues and 
confusion. She requires maximum assistance for bed mobility and min-maximum assistance for transfers. She 
is weight-bearing as tolerated. 
 
The member has stabilized medically and is ready for discharge from the hospital. The member does not 
require skilled nursing and/or skilled therapy services on a daily basis.  She is medically stable and can receive 
further rehab services at a lower level of care. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the peripheral nerve block provided on September 29, 2021. 
 
You asked the Plan to pay for the peripheral nerve block. You say that this code was used to describe 
postoperative pain management and is separately payable. The Plan denied your request. The Plan says this 
claim was denied due to coding standards. However, during the appeal medical records were requested to 
determine if the services could be reimbursed. No medical records were submitted within the time frame 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the peripheral nerve block provided on 
September 29, 2021. have been met. Specifically, medical records were not submitted with the required time 
despite two requests dated January 27, 2022, and February 3, 2022. Therefore, we decided that the Plan does 
not have to pay for the peripheral nerve block provided on September 29, 2021.