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

 
We decided that the Plan does not have to pre-approve a Cardio MEMS device. 
 
You asked the Plan to pre-approve a Cardio MEMS device. You say that the enrollee meets the FDA approved 
labeling for the requested procedure. You say that the enrollee is currently at risk for future heart failure related 
hospitalizations. You say that management by conservative means only is ineffective for stage III chronic 
kidney disease (CKD.) The Plan denied your request. The Plan says there is not enough evidence showing the 
requested device would improve the outcome of the enrollee's condition. 
 
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 Cardio MEMS device. Our reviewer 
says that a Cardio MEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 Cardio MEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cardio MEMS device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have significant low back pain and leg 
weakness and not enough strength to stand without assistance. The Plan denied your request. The Plan says the 
stay is not medically necessary based on SNF 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 physician reviewer 
found 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 SNF 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 SNF care.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to perform basic life functions and 
need SNF care. The Plan denied your request. The Plan says that you are receiving adequate and necessary 
intensive rehabilitation in the inpatient rehabilitation facility (IRF). All the services you need are offered at the 
IRF. 
 
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 SNF 
care is medically necessary. Our physician reviewer found that admission to a SNF is reasonable and necessary 
as you are not making significant progress in the expected period staying in the IRF and hence you need a 
lower level of therapies provided in a SNF. You need skilled therapies daily in an inpatient setting at the 
current functional level as you have made minimal progress with aggressive IRF level of therapies. Continued 
therapy in a SNF is justified for a patient only 6 weeks post stroke to change functional status. The 
documentation supports the need for an admission to an SNF. Your medical record shows that you require 
daily skilled therapy on a daily basis in a SNF 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 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 pay for additional payment of the acute inpatient hospital care 
provided from June 3, 2021, to June 4, 2021. 
 You asked the Plan to pay for the services. You say that the billing of the diagnoses is supported. The Plan 
denied your request. The Plan says the principle diagnosis code A41.9 and secondary diagnosis code J96.01, 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
enrollee was admitted, her condition stabilized and improved and she was discharged home on 06/04/2021. 
There was no clinical or laboratory evidence of sepsis and no evidence of acute respiratory failure with 
hypoxia. The review has determined that the provided documentation did not support the billing of primary 
diagnosis code A41.9, sepsis, unspecified organism. The provided documentation did not support the billing of 
secondary diagnosis code J96.01, acute respiratory failure with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for additional payment of the acute inpatient hospital care provided from June 3, 2021, to June 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that you have felt better after therapy sessions. 
The Plan denied your request. The Plan says a plateau in treatment has been reached. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had prior 
therapy and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. You should be able to transition to an independent home 
exercise program at this point. The requested services are not part of a maintenance program, and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the enrollee has symptoms that 
require insertion of SubQ cardiac rhythm monitor with programming. You say that the enrollee was diagnosed 
with sinus bradycardia on May 2nd and needs treatment, per doctor orders. The Plan denied your request. The 
Plan says an implantable loop recorder is best used for monitoring occurrence of infrequent arrhythmias in 
patients with cryptogenic stroke or recurrent unexplained syncope. The Plan says that an implantable loop 
recorder is not indicated for routine monitoring of asymptomatic patients with sinus bradycardia or short runs 
of supraventricular tachycardia seen on Holter. 
 
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 an implantable loop recorder. Our 
reviewer says that an implantable loop recorder is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. There is 
insufficient documentation to support the medical necessity for insertion of an implantable loop recorder in this patients clinical management. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Temozolomide. 
 
You asked the Plan to pre-approve Temozolomide. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says that this drug is not being prescribed for 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 Temozolomide. Our reviewer says that 
the requested drug is medically necessary for the enrollee's condition. Our physician reviewer found the 
enrollee has been diagnosed with metastatic melanoma BRAF mutation in the central nervous system. In this 
case, the requested use of Temozolomide is not FDA-approved for the enrollees diagnosis. However, the use 
of Temozolomide is in fact supported by one of the major drug compendia or by clinical research that appears 
in a Medicare-approved medical journal. There is off-label use for brain metastases from solid tumors and 
support for combination in medical literature when the enrollee has exhausted immunotherapy and other 
options. This is supported in the document titled "Evolving Role of Chemotherapy-Based Treatment of 
Metastatic Melanoma" in the source titled Cutaneous Melanoma. The requested drug is medically reasonable 
and necessary for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Temozolomide have been met. Therefore, we decided that the Plan has to pre-
approve Temozolomide.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; second level (CPT code 64494 x 2)  and injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493 x 2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary due to wedge 
compression fracture of first lumbar vertebra, initial encounter for closed fracture. The Plan denied your 
request. The Plan says coverage criteria for approval of the requested procedure includes moderate to severe 
chronic neck or low back pain, pain present for at least three (3) months with failure to respond to conservative 
treatment, absence of untreated radiculopathy (symptoms caused by a pinched nerve) or neurogenic 
claudication (leg pain or difficulty walking due to nerves), and no non-facet pathology that could explain the 
source of the enrollee's pain. The Plan states imaging, and assessment revealed an acute fracture; therefore, the 
coverage criteria have not been 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 the services. Our physician reviewer 
found the enrollee clearly has another pain generator that has not been addressed. Facet injections criteria limit 
their use to situations where there is no probable alternative pain generator. The request 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (CPT 
code 64494 x 2)  and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that you fell and broke your ribs, and you are unable 
to walk on your own. The Plan denied your request. The Plan says you do not meet criteria for SNF care and no 
longer require skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found there 
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve GenVisc 850 for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria. 
 
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 the injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the medications 
were injected in an off-label manner.  The request is deemed not medically reasonable or necessary. The 
enrollee was approved for a series of three injections to be given weekly, not monthly. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve GenVisc 850 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that SNF care remains medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 continued SNF care. Our reviewer says 
that SNF care is no longer medically reasonable and necessary. Our physician reviewer found at the time of 
admission, the member required skilled rehab services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs. As of May 29, the member did not require any skilled 
nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of 
daily living. The member did not require skilled therapy to establish a safe and effective maintenance program.  
As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of 
care as of May 29, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 not medically necessary. Our physician reviewer found that you are an 83-year-old male 
seen for memory problems. Based on review of the very limited and available records, admission to a SNF is 
not reasonable and not necessary as you have no skilled nursing needs and do not need skilled therapies 
without documentation of his functional status. Documentation does not support the need for an admission to 
an SNF.  
 
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 admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Blenrep. 
 
You asked the Plan to pre-approve Blenrep. You say that the enrollee is not on Velcade. The Plan denied your 
request. The Plan says medical studies have not proven that the requested drug is helpful for treatment of the 
enrollee's health problem when used with Velcade. 
 
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 Blenrep. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Blenrep is not 
FDA-approved for the enrollee's diagnosis. The use of this drug is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Blenrep have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Blenrep.