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

 
We decided that the Plan does not have to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that the requested Pembrolizumab is medically 
necessary. The Plan denied your request. The Plan says the requested Pembrolizumab is not medically 
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 Pembrolizumab. Our reviewer says that 
the requested Pembrolizumab is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of stage IV colon adenocarcinoma.  The requested agent is being used as first 
line treatment in the setting high tumor marker burden.  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.   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 Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab.
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 enrollee has decided to actively participate and 
work with her therapists and meets SNF criteria. The Plan denied your request. The Plan says criteria for 
admission to a SNF 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  She is medically stable and can receive further rehab services at a lower level of 
care.  Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication; complex wound care or nutrition given via a feeding tube.  She is 
medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or 
near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services is 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis (L3670) provided on October 7, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the shoulder orthosis (L3670) provided on October 
7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria. 
 
 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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the request exceeds utilization 
criteria of no more than 2 levels to be treated at one session. Only 2 levels are 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. 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 a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records are not clear 
on this issue; a progress note dated March 8, 2022 reports the enrollee is "nonambulatory for several months" 
yet the same note also states she is "highly dependent on assistance for ambulation" and "requiring full assist 
(walker, or assistance)." The certificate of medical necessity and other records are also contradictory on this 
point. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services (A0429 and A0425) 
provided on May 26, 2021. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not a 
covered destination. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance services. Our 
reviewer says that the provided records document no physical or mental condition (need for intravenous lines, 
isolation status, dementia with agitation, etc.) which would have been a contraindication to transport by 
stretcher van.  
 Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. 
 
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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent ambulance services (A0429 and A0425) provided on 
May 26, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane. 
 
You asked the Plan to pre-approve Abraxane. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
 
 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 Abraxane. Our reviewer says that the 
medication is necessary. Our physician reviewer found the provided records do not indicate that the enrollee 
has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred step one alternative. 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 Abraxane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Abraxane.
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 does not 
appear likely to tolerate or benefit from intense therapies. 
 
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 you were admitted to the acute care hospital for elective laparotomy with extensive surgery including 
radical tumor debulking, bilateral salpingo-oophorectomy, and lymphadenectomy. The documentation does not 
support that you require at least 3 hours a day. It is not clear that you are reasonably expected to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF 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: 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 the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this care is not medically necessary and you can receive wound care in the home. 
 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are 
ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a 
daily basis. You are medically stable and can receive further rehab services at a lower level of care.  Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and you can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 the admission 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 18, 
2021 by an out-of-network (OON) provider.
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 SNF care is medically necessary because you are 
not independent and need further rehabilitation due to the physical and cognitive deficits from your stroke. The 
Plan denied your request. The Plan says admission to a SNF is not medically necessary. 
 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 have stabilized medically and have been 
receiving skilled rehab services in an inpatient rehabilitation facility (IRF).  You no longer require daily skilled 
nursing and/or skilled therapy services.  You could benefit from continued intermittent services at a lower level 
of care.  Although you made slow progress with therapy, your functional improvement has plateaued, there is 
no indication that transfer to a skilled nursing facility is required.  
 
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: 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 you need SNF care in order to function.  You said 
that you are not stable on your feel and are unable to walk on your own.  You said that you would be a fall risk 
when you return home. The Plan denied your request. The Plan says SNF care is not medically necessary. 
 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 have stabilized medically and are ready 
for discharge from the hospital.  You do not require skilled nursing and/or skilled therapy services on a daily 
basis.  You are medically stable and can receive further rehab services at a lower level of care.  Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility.  You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube.  You are medically stable without any 
acute exacerbations of chronic medical problems.  Your physical function is at or near her baseline and you can 
receive services 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (97110). 
 
You asked the Plan to pre-approve physical therapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 physical therapy. 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 patient has had prior PT and the documentation does not reveal 
that the patient requires the ongoing unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The patient is compliant in a HEP. 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 the patient's 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy (97110).
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 the admission. You say that this is medically necessary. 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal 
evidence of complex wound care or other skilled nursing SNF need. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist  to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, you do not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).