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

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that physical therapists have deemed her unsafe for 
discharge back to her assisted living facility with recommendation for discharge to a short-term skilled nursing 
facility. You say that she is making progress with physical therapy and is a good rehab candidate. The Plan 
denied your request. The Plan says the enrollee is not meeting medical necessity criteria for skilled nursing 
level of care. The enrollees needs can be safely met at a lower level of care.  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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that there is no documentation that the 
enrollee requires skilled nursing services. Although the enrollee does require skilled therapy services, there is 
no documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the home with home health care or in a long-term care facility on a part time basis are 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced life support (ALS) routine disposable supplies 
(A0398) provided on December 19, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were admitted to the hospital after a 
stroke. You also say that you were not told of the amount of the denial. The Plan denied your request. The Plan 
says routine supplies are not covered services. 
 
The Plan must follow Medicare rules. Medicare rules say that the fee schedule for ambulance services 
precludes a separate payment for items and services furnished under the ambulance benefit. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay 
for the advanced life support (ALS) routine disposable supplies (A0398) provided on December 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled physical therapist to make more visits at 
this time. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services are not medically reasonable or necessary. Our physician reviewer found you do not have 
documented ongoing home health physical therapy (HH/PT) needs. You appear to be functioning at a level 
commensurate with a lower level of care, such as a home exercise program or outpatient therapy. As such, the 
requested ongoing HH PT services are not medically necessary or reasonable. 
 
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 home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Amitiza capsule, 24 mcg. 
 
You asked the Plan to pre-approve Amitiza. You say that the enrollee has been stable on this medication for 
years. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Amitiza capsule, 24 mcg.  
 Benefits for Amitiza 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bevacizumab-Awwb (MVASI) injections. 
 
You asked the Plan to pre-approve Bevacizumab-Awwb (MVASI) injection. You say that the requested 
Bevacizumab-Awwb (MVASI) injection is medically necessary. The Plan denied your request. The Plan says 
the requested Bevacizumab-Awwb (MVASI) injection 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 Bevacizumab-Awwb (MVASI) 
injection. Our reviewer says that the requested Bevacizumab-Awwb (MVASI) injection is not medically 
necessary. Our physician reviewer found the requested use of Bevacizumab-Awwb is not FDA-approved for 
the enrollee's diagnosis. 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, not in combination with Carboplatin alone. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bevacizumab-Awwb (MVASI) injection. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Bevacizumab-Awwb (MVASI) injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this procedure is experimental. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. 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 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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the service is 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 SNF care have not been met. Specifically, medically necessary services can 
be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve the 
skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not indicate any prior laboratory studies. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no Mini Mental 
State Examination (MMSE) result or equivalent testing cognitive function. In addition, there are no laboratory 
values of thyroid-stimulating hormone, vitamin B12, or folate are in the records. The neurological exam is 
negative. Absent the above listed information, the medical necessity of a brain MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee.
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 the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, as a practical matter, can be provided 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat with a bidet. 
 
You asked the Plan to pre-approve a raised toilet seat with a bidet. You say that a raised toilet seat with a bidet 
is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, 
neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to 
pre-approve a raised toilet seat with a bidet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herceptin. 
 
You asked the Plan to pre-approve Herceptin. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements of 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 Herceptin. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of metastatic cervical cancer with PDL-1 15%, microsatellite stability, high TMB and ERBB2 
(HER2). The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals 
were submitted for review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herceptin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Herceptin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the crutch substitute (E0118) purchased 
on November 23, 2021, and the related sales tax (S9999). 
 
You asked the Plan to provide reimbursement for the crutch substitute. You say that it was not recommended 
that you use crutches. Your doctor felt that this substitute was more appropriate. You feel that this expense 
should be reimbursed. The Plan denied your request. The Plan says this equipment is not covered by Medicare 
at this time. 
 The Plan must follow Medicare rules. Medicare rules say that the medical necessity of products described by 
code E0118 is not supported based on current information. 
 
We looked at the file and Medicare rules. Although this DME may have been appropriate, neither Medicare nor 
the Plan provides coverage for this item. Since the item is not covered, the sales tax is also not covered.  Based 
on this information, we decided that Medicare rules for coverage of the crutch substitute have not been met. 
Therefore, we decided that the Plan does not have to provide reimbursement for the crutch substitute (E0118) 
purchased on November 23, 2021, and the related sales tax (S9999).
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: 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 enrollee has active rectal cancer and has already 
received the other treatment options that were unable to aid in the enrollee's diagnosis. You say that the 
enrollee cannot wait longer to receive the requested medication without having his cancer progress. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for coverage of the requested 
drug. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of metastatic adenocarcinoma, most likely of hepatobiliary origin that is MSI stable and not 
microsatellite instability-high (MSI-H) and/or deficient mismatch repair (dMMR) or tumor mutational burden 
high (TMB-H). The record provided does not support the appeal claim that the enrollee has rectal cancer. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level or given your fatigue level noted in therapy that you can tolerate 
an intensive IRF program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve astigmatic keratotomy (S9986). 
 
You asked the Plan to pre-approve astigmatic keratotomy. You say that you would like to appeal the denial for 
your lenses because you really need this. You are worried about the lens cost and was quoted $850, which is 
very expensive for you. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve astigmatic 
keratotomy (S9986).
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 the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with left basal ganglion intracerebral hemorrhage with intraventricular hemorrhage and 
hypertensive emergency. The record indicates that the enrollee is improving but still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied.  The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility.  The elements of the coverage rules 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 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.