Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for lumbar laminectomy surgery provided on January 28, 2021.  You asked the Plan to pay for lumbar surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the clinical documentation does not indicate that this procedure was necessary to treat the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for lumbar surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had severe back pain that was negatively impacting the enrollee's life. The enrollee failed to respond to multiple conservative measures, and imaging demonstrated significant spinal canal stenosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar surgery have been met. Therefore, we decided that the Plan has to pay for lumbar laminectomy surgery provided on January 28, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only ohe 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 reviewer says that the
services are not medically necessary. Our physician reviewer found there is radiologic evidence of progression
of disease while being treated with Keytruda. Continued use of Keytruda is not considered medically
reasonable and necessary in this setting. The continued use is not expected to be safe and effective for the
enrollee in this case, as there has been progression of disease while receiving the drug.
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 Keytruda
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the services related to an implanted
stimulator provided on May 26, 2021.
You asked the Plan to waive the coinsurance for the services related to an implanted stimulator. You say that
you were never informed of the cost of the coinsurance. The Plan denied your request. The Plan says the
correct coinsurance was applied.
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 20%
coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics. The
total amount allowed was $5041.23. The coinsurance amount is $1008.24 ($5041.23 x 20% coinsurance).
You have been asked to pay a 20% coinsurance for services related to an implanted stimulator. Services related
to implanted stimulator falls within the Prosthetic devices and related supplies 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 coinsurance for the services related to an implanted stimulator provided on May 26,
2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your reported decreased endurance, fatigue and shortness of breath with therapy. Care at the skilled nursing facility level appears to be appropriate in this case.  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 pre-approve proton beam radiation therapy with hydrogel spacer for
the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no clear evidence and or compelling data to suggest that proton beam therapy
for prostate cancer offers any clinical advantage over other radiotherapy modalities such as intensity-modulated
radiation therapy (IMRT) or image-guided radiation therapy.
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 therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found an appeal includes an "example comparative treatment plan" that is not the enrollee's plan. The proton
plan achieved more than 50% reductions in the mean dose to the rectum and bladder, and uses reduced
malignancy risk as a justification of need for this patient.
The appeal letter mentions the NCI risk assessment tool - though it is unknown how the data from radiation
treatment planning would apply to this calculator or how this example patient would apply to this enrollee. Any
potential benefit or detriment of proton therapy over standard IMRT is an investigational question being pursed
in randomized studies. Other treatment approaches are also highly effective and well tolerated. Thus, whether
proton therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation
and remains controversial. Particularly with the use of the SpaceOAR hydrogel spacer, the risk of
gastrointestinal/rectal toxicity is low (since the rectum is pushed away from the prostate) such it is even more
unlikely that there would be a potential benefit from proton therapy. To date, there are no compelling data to
suggest that proton therapy is superior to or more beneficial than standard approaches. The generally accepted
standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely
offer it to patients.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve proton beam radiation therapy with hydrogel spacer for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).  You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 3D radiation with IGRT is not an accepted standard of care for routine use in the palliative treatment of bone metastases.        We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable controller harness (E2313).  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that it is not medically necessary to control the three approved power options through the joystick (drive interface).  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 requested services are not considered medically reasonable and necessary in this case. The requested items exceed your medical need. You do not require non-proportional input devices. You do not require a separate display, other electronic devices, or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but your upper extremity strength and function support that you can control any power options through their own switches. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable controller harness (E2313).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Timolol maleate for the enrollee.
You asked the Plan to pre-approve this drug. You say that if the patient does not receive this medication the
patient can develop peripheral vision loss. The Plan denied your request. The Plan says that this is not covered
under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Timolol maleate for the
enrollee.
Benefits for this drug 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 pre-approve proton treatment delivery.
You asked the Plan to pre-approve proton treatment delivery. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria
have not been met.
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 proton treatment delivery. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found based on currently available evidence, the proton therapy will be considered 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 proton treatment delivery have not been met. Therefore, we decided that the
Plan does not have to pre-approve proton treatment delivery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. You say that this is medically necessary. The Plan denied your
request. The Plan says that you do not meet step therapy criteria.
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 Neulasta. Our reviewer says that
Neulasta is not medically reasonable and necessary. You have not tried and failed the required drugs. Zarxio is
a biosimilar and is a standard therapy with similar efficacy to Neulasta. Our physician reviewer found that your
condition does not meet step therapy criteria for Neulasta.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have
to pre-approve Neulasta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary for the patient's
treatment of Alzheimer's disease with early onset. The Plan denied your request. The Plan says that the use of
Aduhelm in this member is not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Aduhelm. Our reviewer says that
Aduhelm is not medically reasonable and necessary. Aduhelm is not FDA-approved for the enrollee's
diagnosis. Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive
impairment or mild dementia stage of disease. The enrollee is reported to have severe short-term memory
deficit; however, the case file does not contain results of recent cognitive testing, MMSE.
The documentation does not support that the enrollee has mild cognitive impairment or mild dementia stage of
disease. The use of Aduhelm is not supported by one of the major drug compendia or by clinical research that
appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of Aduhelm.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aduhelm for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Infed.  You asked the Plan to pre-approve Infed. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Infed. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Infed is medically reasonable or necessary for the enrollee. The documentation does not support that the Infed is safe and effective 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 Infed have not been met. Therefore, we decided that the Plan does not have to pre-approve Infed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that there is no advantage in transferring to the LTACH at this
time.
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 shortterm
acute care hospital can provide for all of the patient's present inpatient care needs and the patient is
receiving an appropriate level of care in the present setting. The patient does not have a stable tracheostomy or
stable percutaneous gastrostomy feeding tube for safe transfer to an LTACH.
Continued care in the short-term acute care hospital is appropriate until the patient is stable to transfer to an
LTACH or to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility
or a skilled nursing 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-approve LTACH services for the enrollee
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing provided on August 17, 2021.  You asked the Plan to pay for the testing services. You say that the test informs clinicians about which medications may require dose adjustments. The Plan denied your request. The Plan says the testing has not been shown to be useful.  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 provided pharmacogenetic testing was reportedly ordered to make decisions about the patient's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a patient's response to the medication. The testing is not considered reasonable and necessary merely on the basis of a patient having a particular diagnosis. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the mechanical traction therapy (97012) and electrical stimulation (G0283) provided on August 13, 2021.  You asked the Plan to pay for the mechanical traction therapy and electrical stimulation. You say that this claim should be reprocessed based on Medicare guidelines. The Plan denied your request. The Plan says services rendered by a chiropractor other than manual manipulation of the spine are not covered.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.       The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the mechanical traction therapy (97012) and electrical stimulation (G0283) provided on August 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion device.  You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.