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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that based on enrollees ongoing and complex 
medical needs, the enrollee cannot be adequately cared for in their current condition at a skilled nursing 
facility. They require prolonged hospitalization and close physician monitoring. The Plan denied your request. 
The Plan says the request is not medically necessary, when the enrollee is ready to leave the hospital, they can 
safely receive this 
care in another setting, such as an Inpatient Rehabilitation Facility (IRF) or a Skilled Nursing Facility (SNF). 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee surgery. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
and comprehensive less invasive conservative care measures for the left knee. Moreover, the appeal letter noted 
the left knee had a positive McMurrays test. She has severe pain along the medial joint line and range of 
motion is 5-95 with a mechanical block to full flexion and extension. Moreover, there is documentation of 
degenerative changes in the left knee. There are limited large-scale, long-term references showing the safety 
and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left knee surgery.
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. The Plan denied your request. The Plan says the enrollee is not 
able to tolerate an intensive rehabilitation program. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for respiratory failure, congestive heart failure and 
pneumonia. Her medical problems are stable. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
The complexity of the enrollees 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the IRF. You say that further delay in care will have a detrimental effect on the enrollee's safety, ability to 
recover, be discharged to a community setting, and stay in that community setting, averting unplanned 
readmissions. The Plan denied your request. The Plan says criteria for admission to the IRF 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 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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for Ehlers-Danlos Syndrome. 
 
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 genetic testing 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 not medically necessary. Our physician reviewer found the submitted records do not state how 
the requested testing will impact your future care. In addition, the validity of the testing is not certified for the 
requested laboratory. The testing is not reasonable or medically necessary at his time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing for Ehlers-Danlos Syndrome.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 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 enrollee was admitted to the hospital on November 11, 2022 for left heel and 
great toe osteomyelitis that required excisional debridement. The occupational therapy evaluation on November 11, 2022 indicates he was using a  walker for mobility prior to hospitalization. As of November 27, 2022 he 
required moderate assistance of two for standing and transfers and was non-ambulatory. He does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. He has had a functional decline from his baseline level of function, but it is unlikely that he 
can participate in and benefit from the intensity of therapies provided on acute inpatient rehabilitation. It is 
unclear if he can tolerate the intensity of therapy provided on acute inpatient rehabilitation at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 waive the copayment for an outpatient surgery provided on March 
10, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you are requesting a 
reconsideration on the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $360 
copayment for in-network outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $360 copayment for an outpatient surgery. However, you are only being asked to 
pay $287.26 which is less than the required amount. This item/service falls within the in-network outpatient 
surgery/outpatient hospital 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 an 
outpatient surgery provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested services. You say that you need the device to prevent blood 
clots. The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The requested device, used for a preventative service is excluded 
from coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression 
device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
the Minuteman interspinous device in the setting of spinal stenosis has not been demonstrated in the peer-
reviewed literature, especially when compared to standard alternatives. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 57-year-old female being treated for intervertebral disc 
degeneration of the lumbar region. She presented with low back and leg pain that started 8 weeks ago and is 
rated 7/10 or higher. The pain radiates down the right greater than the left leg. The pain is shooting and electric 
shock when radiating.  
 
In this case, current evidence-based medical guidelines and peer-reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. According to the Food and Drug Administration (FDA), The HA Minuteman G3-
R MIS Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for use at a single level 
in the non-cervical spine (T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone 
graft material and is not intended for stand-alone use. 
 
In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability 
have not been documented and/or met in this case. In addition, there are multiple alternate pain generators 
plausibly significantly contributing to the clinical condition that have not been fully documented as having 
been excluded and/or ruled out. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested Minuteman Procedure 
to L4-5, in this case, is not medically reasonable or 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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would benefit from long term acute 
care services due to your medical complexity. The Plan denied your request. The Plan says the services needed 
could be provided in another setting such as subacute rehabilitation. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 would benefit from long-term acute care 
due to medical complexity. The Plan denied your request. The Plan says the services needed could be provided 
in a lower 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 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cisplatin, Alimta, and Keytruda. 
 
You asked the Plan to pre-approve Cisplatin, Alimta, and Keytruda. You say that this is medically necessary. 
The Plan denied your request. The Plan says this use of these drugs is not supported. 
 
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 Cisplatin, Alimta, and Keytruda. Our 
reviewer says that the requested use of Cisplatin, Alimta, and Keytruda is not supported. Our physician 
reviewer found this drug combination is not Food and Drug Administration (FDA)-approved for the enrollees 
diagnosis. It is not a standard first line therapy for malignant pleural mesothelioma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cisplatin, Alimta, and Keytruda have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Cisplatin, Alimta, and Keytruda.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart (75571). 
 
  You asked the Plan to pre-approve a CT of the heart. You say that because of your age and family history, your 
doctor ordered this test to determine what, if any medications or recommendations might be made to avoid 
serious future heart problems. The Plan denied your request. The Plan says Medicare does not cover a 
screening Coronary Computed Tomography Angiography (CCTA) for asymptomatic patients, for risk 
stratification, or for quantitative evaluation of coronary calcium. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a CT of the heart, is being requested solely for screening purposes of coronary 
calcifications due to your family history. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart 
(75571).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the records provided support the need 
for the services which remain in dispute. The Plan denied your request. The Plan says the clinical value and 
effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the 
peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that bone marrow aspirate is not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental, and more research is 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the use of this requested drug is not reasonable and 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 Opdivo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of stage IV metastatic non-small cell adenocarcinoma of the lung.  The record provided does not 
document the PDL-1 status or whether tumor marker mutations are present.  The record provided is insufficient 
to determine whether coverage criteria are satisfied. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  No literature 
from Medicare approved cancer journals were submitted for review.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.