Persius/hicric huggingface dataset:
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 are wasting away in the hospital and need to 
exercise for the best cure for your Parkinson's disease. The Plan denied your request. The Plan says ongoing 
skilled care can be provided in an alternative setting. 
 
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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical and occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that ESI will be considered medically reasonable and 
necessary when certain requirements 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does reveal that you have a positive right Spurling's sign but the documentation does not reveal a clear 
distribution of this pain or that there is specific dermatomal/myotomal deficits in a specific nerve root 
distribution. There is no evidence of an objective cervical imaging study. There is no evidence of post-
laminectomy or acute herpes zoster pain. There is no evidence of the location and outcome of prior cervical 
epidural injections with at least 50% sustained improvement in pain relief and/or function from baseline for 3 
months. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Life2000 ventilator. 
 
You asked the Plan to pre-approve Life2000 ventilator. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2000 ventilator. Our reviewer says 
that the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic 
obstructive pulmonary disease. The provided records document that the home ventilator is being requested for 
use with very low set tidal volumes (150 to 200 mL) which could be provided by a BiPAP device with average 
volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and 
failure of a bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Claims for 
ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy will be 
denied as not reasonable and necessary. Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Life2000 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Life2000 ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty (22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value, effectiveness, and safety of a kyphoplasty/vertebroplasty 
in the setting of a remote vertebral compression fracture with retropulsion has not been demonstrated in the 
peer-reviewed literature. 
 
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 service. Our physician reviewer 
found there is no documentation of a trial of bracing. More conservative measures are needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the kyphoplasty (22514).
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 pembrolizumab use is considered category 2A 
according to guidelines. The Plan denied your request. The Plan says Keytruda is not indicated for 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 Keytruda. Our physician reviewer 
found that the enrollee has hormone refractory prostate cancer. The drug is not approved for the enrollee's 
diagnosis as the enrollee has not had chemotherapy. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records do not show that they are without facet arthritis 
correlated with facet-mediated pain at levels L3-S1. 
 
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 intracept procedure. Our physician 
reviewer found the magnetic resonance imaging (MRI) shows lumbar disc herniation at L5-S1. The LCD 
criteria have not been 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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary for treatment of the 
enrollee's condition. The Plan denied your request. The Plan says the records do not show continued usage of 
the ventilator greater than or equal to 4 hours daily. 
 
The Plan follows Medicare rules. Medicare rules state that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, shall not be 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 ventilator. Our reviewer says that the 
enrollee does not meet criteria for use of a ventilator. Our physician reviewer found the records document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
document that the home ventilator is being requested for use with very low set tidal volumes (150 mL to 200 
mL) which could be provided by a BiPAP device with AVAPS and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued use of a ventilator.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve use of Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that this is not a medically accepted indication for Tecentriq. 
 
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 Tecentriq. Our reviewer says that the 
enrollee meets criteria for Tecentriq. Our physician reviewer found the enrollee has high-grade neuroendocrine 
cancer of the rectum which is metastatic. This is treated as extensive small cell cancer. The first 2 cycles are 
platinum/etoposide. Tecentriq is added to cycle 3. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have been met. Therefore, we decided that the Plan has to pre-
approve use of Tecentriq.  
 
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 a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the enrollee 
attempts to control his symptoms via less conservative therapies that are well documented with the persistence 
of symptoms. The Plan denied your request. The Plan says records do not show that the enrollee has edema 
extending to his trunk, that he has tried a non-segmental or a segmental model without calibrated gradient 
pressure (E0650 or E0651), or that the device was ordered by his treating physician. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, chest (E0657).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair 
 
You asked the Plan to pre-approve a power wheelchair. You say that you wish to appeal the denial of the power 
wheelchair. The Plan denied your request. The Plan says the power wheelchair is not medically necessary for 
the enrollee's current mobility needs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of spinal stenosis and surgery. Per the physician note the 
enrollee has normal strength in upper and lower extremities and is able to self-transfer. The records does not 
support the enrollee require a power wheelchair versus a standard wheelchair to perform MRADL's. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you don't meet the requirement. The requirement is you need daily skilled nursing 
care or rehabilitation services that are reasonable and necessary for the treatment of your illness or injury. You 
can receive the care you need in another setting, such as home, a long- 
term care facility, or other outpatient setting. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found Evaluating therapists recommend ongoing skilled therapy in a skilled nursing facility 
and you are beneath documented past level of function status thus daily skilled services on an inpatient basis in 
a skilled nursing facility is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: 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 enrollee meets the criteria for Acute Inpatient 
Rehabilitation and will benefit from Acute Inpatient Rehab that cannot be accomplished at a lower level of care 
The Plan denied your request. The Plan says the enrollee's records do not show that rehabilitation needs are not 
complex, services needed can be provided safely in other settings, a skilled nursing facility, home with home 
health services or home with outpatient therapy. 
 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 enrollee needs authorization for the ability to 
regain maximum function could be seriously jeopardized by applying the standard timeframe in processing this 
request. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an Inpatient Rehabilitation Facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current facility and no specialized services provided by the LTACH have been 
identified that are not available to the member in the current 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. Our 
physician reviewer found the record indicates that the enrollee has ongoing medical issues and still requires 
acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care 
services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. The elements 
of the coverage rules are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monoferric. 
 You asked the Plan to pre-approve Monoferric. You say that the enrollee has tried Feraheme and Infed in the 
past. The Plan denied your request. The Plan says the enrollee has not tried the preferred drugs. 
 
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 Monoferric. Our physician reviewer 
found that the enrollee has iron deficiency anemia. The Plan requires a trial of Infed and Venofer before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is 
no documentation provided indicating that the Plans required drugs would likely be less effective or likely 
have adverse effects 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 Monoferric have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Monoferric.