Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of skin substitute graft (15275). 
 
You asked the Plan to pre-approve the application of skin substitute graft. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 
services are not medically reasonable and 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 application of skin substitute graft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the reviewed documentation indicates that the member is receiving 
antibiotic medications for treatment of osteomylitis and that bone is exposed at the base of the wound. 
Additionally, the Plan did not receive any indication that there has been assessment of adequate blood supply to 
the area and the medical records indicate that there is edema to the area. The review has determined that the 
items/services at issue in this case are 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 application of skin substitute graft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the application of skin substitute graft (15275).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that this will help improve the patient's quality of
life. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 vertiflex device
is experimental. More research is needed. Our physician reviewer found that the enrollee's 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 the Vertiflex device for the enrollee.
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 enrollee had a response to Keytruda based 
combination therapy. The Plan denied your request. The Plan says the clinical effectiveness of Opdivo has not 
been demonstrated 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 Opdivo. Our physician reviewer found 
that the enrollee has metastatic non-small cell lung cancer. The requested use of Opdivo is not FDA-approved 
for the enrollee's diagnosis. PD1 inhibition with Keytruda has been tried and failed. As the enrollee has failed 
Keytruda, Opdivo, another PD1 inhibiter, is not reasonable and necessary. The requested use is not supported 
by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
The use is not listed as not indicated, not supported or not recommended in any of the compendia. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The Plan denied your request. The Plan says you must be between 55 and 77 years of age.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. We reviewed the file and the Medicare rules. We find that you are 51 years old, which is outside the coverage age range for this screening. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand of diabetic test strips.
You asked the Plan to pre-approve the requested items. You say that the requested brand is what the enrollee is familiar with. The Plan denied your request. The Plan says the enrollee has not tried the preferred testing supplies.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred.
The requested brand of diabetic supplies is not a preferred brand. The Plan has preferred brands available for the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand of diabetic test strips.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 documentation provided the enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you had stable vital signs, uncomplicated 
wound care to your right buttock and treated for pain. You were at a standby assist to contact guard assist level 
for functional mobility including gait to 50 feet. You do not require skilled nursing or therapy services on a 
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 the patient's immediate acute needs have been addressed and she is no longer appropriate for short term acute hospital care. You say that at this time the patient is medically optimized to transition to the next level of care. The Plan denied your request. The Plan says admission to a long-term care hospital is not medically necessary.
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 does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The enrollee is receiving appropriate care at the present acute care hospital. 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Tecentriq (J9022). 
 
You asked the Plan to pre-approve Tecentriq. You say that this is a continuation of care. You also say that the 
enrollee is already in treatment but is just changing providers/facility. The Plan denied your request. The Plan 
says that the submitted diagnosis of Head and Neck Small Cell Cancer is not a medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our reviewer says that 
Tecentriq meets the criteria for coverage. Our physician reviewer found the continuation of Tecentriq for small 
cell neoplasm with response meets compendia and will be approved. 
 
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 Tecentriq (J9022).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470), certified translation or sign-
language services (D9990), and a crown (D2740) for tooth #5. 
 
You asked the Plan to pre-approve the diagnostic casts, certified translation or sign-language services, and 
crown. You say that you would like these services to be approved by the Plan. The Plan denied your request. 
The Plan says the diagnostic casts and certified translation or sign-language services are not covered services. 
The Plan also says that the crown for tooth #5 exceeds the benefit allowance because the service is limited to 
one per tooth every 60 months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, diagnostic casts (D0470) and certified 
translation or sign-language services (D9990) are not among those covered under this benefit. The contract 
says that crowns (D2740) are limited to one per tooth per 60 months. The record shows that you received a 
crown (D2740) on tooth #5 on July 30, 2019 and your crown (D2740) benefit for tooth #5 has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (D0470), certified translation 
or sign-language services (D9990), and a crown (D2740) for tooth #5.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wrist replacement surgery (25442).
You asked the Plan to pre-approve wrist replacement surgery. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested wrist replacement surgery is not medically necessary as the presentation of exactly what is wrong and what is proposed is unclear.
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 wrist replacement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for the requested surgery have not been met as more clinical information is needed. Before this surgery can be approved, more info is needed on the patient's diagnosis, imaging results, and clinical treatments 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 wrist replacement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve wrist replacement surgery (25442).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orthofix Trinity Elite allograft. 
 
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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Orthofix Trinity Elite allograft 
remains experimental for use in the posterior thoracic spine. More research is needed. The services are 
therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Orthofix Trinity Elite allograft.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been 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 there is no documentation provided indicating medical necessity for admission to an 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the criteria for Euflexxa have 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 Euflexxa. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates 
that the enrollee has patella chondromalacia. The records provided do not support a diagnosis of ostearthriitis 
of the knees. The Food and Drug Administration has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied.  
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 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 your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
treatment should only be performed in a prospective clinical trial. 
 
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 requested services. Our physician 
reviewer found that to date, there are no compelling data to suggest that proton therapy is superior to or more 
beneficial than intensity-modulated or image-guided radiation therapy (IMRT/IGRT). 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.  It is even more unlikely that there would be a potential benefit from proton therapy. 
Therefore, the requested services are not considered medically reasonable and 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.