Persius/hicric huggingface dataset:
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 you are being discharged from the hospital and need 
assistance in regaining your strength to your full potential. The Plan denied your request. The Plan says the 
criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided 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: 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. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care and are currently unstable for transfer to an LTACH. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. Our reviewer found that there are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. The 
Plan has approved ongoing care in the current acute care facility. Our physician reviewer also found that the 
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and 
condition 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 intravenous immune globulin (IVIG) with Gammagard. 
 
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 IVIG is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have a diagnosis of idiopathic 
thrombocytopenic purpura (ITP). The records show that your platelet count had responded to dexamethasone, 
with a platelet count of 151,000 on April 4, 2022. Your most recent complete blood count (CBC) results on 
April 7, 2022 showed a platelet count of 269,000. You do not meet the criteria for coverage of Gammagard and 
the services are 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 intravenous immune globulin (IVIG) with Gammagard.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a specialist telehealth visit provided on December 14, 
2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. The Plan denied your request. The 
Plan says that you have been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a complete case file for review. Without a complete 
case file with all the necessary documents, we are unable to confirm the services received or determine if the 
cost sharing applied is correct. Therefore, we decided that the Plan has to waive the copayment for a specialist 
telehealth visit provided on December 14, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 2, 2021, 
to September 28, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan 
denied your request. The Plan says the initial Request for Anticipated Payment (RAP) claim within 5 
calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, September 2, 2021.  Therefore, we decided that the Plan does not have to pay for the home health services provided from September 
2, 2021, to September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda and paclitaxel for the enrollee. 
 
You asked the Plan to pre-approve Keytruda and paclitaxel. You say that these are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Keytruda in 
combination with paclitaxel in the setting of an unknown TMB level and in combination for the treatment of 
cutaneous angiosarcoma have not been demonstrated in the peer-reviewed literature. 
 
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 and paclitaxel. Our reviewer 
says that Keytruda and paclitaxel is not medically reasonable and necessary. Keytruda and paclitaxel are not 
FDA-approved for the enrollees diagnosis. The use of Keytruda and paclitaxel is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda and paclitaxel. 
 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 and paclitaxel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Keytruda and paclitaxel for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
May 30, 2021, to June 13, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you thought you already met 
your deductible, and you should owe $0 for these services. The Plan denied your request. The Plan says this 
claim was processed correctly, and your copayment was assessed in accordance with your contract. You are 
responsible for a $500 copayment for each Medicare-covered inpatient hospital stay after you meet your 
deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 
copayment for each Medicare-covered inpatient hospital stay.  
 You have been asked to pay a $500 copayment for the inpatient hospital stay. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the inpatient hospital care provided from May 30, 2021, to June 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency ambulance response without transport on 
September 20, 2021. 
 
You asked the Plan to pay for emergency ambulance response without transport. You say that you believe the 
Plan should pay this bill. The Plan denied your request. The Plan says emergency ambulance response without 
transport is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on September 20, 2021. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for emergency ambulance 
response without transport on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 7, 2021.
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 patient cannot take care of herself at home and 
she requires a higher level of care. She will need rehab and wound care until she is able to care for herself 
independently. The Plan denied your request. The Plan says the patient can safely receive the services she 
needs at the current hospital. 
 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 is an 80-year-old woman with a 
history of heart failure, diabetes, hypertension, chronic kidney disease, morbid obesity, and an above knee 
amputation of her left lower extremity, who was admitted to the hospital with cellulitis of her left leg stump. 
Surgical debridement was performed on March 27, 2022. She was cleared by surgery for discharge home once 
home health and wound care have been arranged as of March 31, 2022. She was advised to continue wet-to-dry 
dressings twice daily and follow-up outpatient at that time. The enrollee has no skilled nursing needs but she 
would benefit from skilled therapy services. However, the documentation does not support that it is medically 
reasonable and necessary to provide skilled services on a "daily basis" 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intrapyloric injections of Botox. 
 
You asked the Plan to pre-approve the Botox stomach injections. You say that it is felt that this is medically 
necessary. The Plan denied your request. The Plan says this is not a covered indication for this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Botox stomach injections. Our 
reviewer says that the requested use of Botox for this condition is not supported and is not medically 
reasonable and necessary. Our physician reviewer found the enrollee is a male with fatty liver, gastric reflux, 
and possible Crohn's disease. There is epigastric pain and vomiting attributed to gastroparesis, for which Botox 
is requested. 
 
The Medicare compendia do not list gastroparesis as an approved off-label indication for Botox. Though trials 
evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no 
agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric 
emptying study in patients with gastroparesis.   
Almost all the non-randomized trials reported significant improvement in subjective symptoms and objective 
gastric emptying study after botulinum toxin injection. While the 2 randomized controlled trials did not 
confirm the efficacy of botulinum toxin injection, none of the individual trials showed that there was 
statistically significant subjective and objective improvement in the active patients when compared with 
patients receiving placebo.  
 
The record does not support that the enrollee has exhausted all available dose-optimized treatment options for 
gastroparesis, and Botox does not have sufficient evidence of efficacy to support its use in this circumstance. 
 
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 Botox stomach injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve intrapyloric injections of Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider 
on July 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on 
July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve a lumbar facet joint radiofrequency ablation procedure. 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 Facet Joint Interventions are covered when specific 
criteria 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 lumbar facet joint radiofrequency 
ablation procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found you never had any diagnostic block at L1-L2. You had only one set of diagnostic medial branch block (MBBs) which produced 90% pain relief. The criteria is two sets of diagnostic blocks which produce greater 
than 80%. At this point, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar facet joint radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation 
procedure.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) 
scan. 
 
You asked the Plan to pre-approve the FDG PET imaging. You say that It is felt that the likelihood of cancer is 
high enough that PET imaging is warranted. The Plan denied your request. The Plan says that there are no new 
symptoms or covered indication for imaging in records provided. 
 
The Plan follows Medicare rules. Medicare rules say that PET imaging may be covered for enrollees with 
strongly suspected malignancy in order to allow for anti-cancer treatment planning. 
 
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 FDG PET imaging. Our reviewer 
says that the requested PET scan is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of esophageal cancer, and recent imaging has shown an enlarging 
mediastinal lymph node. Biopsies of the esophagus were negative. Given the history and findings, PET 
imaging is reasonable, as the PET being positive would provide information on whether biopsy of the lymph 
node is required and show if cancer is present elsewhere. 
 
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 FDG PET imaging have been met. Therefore, we decided that the Plan has 
to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan.  
 
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 TheraSkin. 
 
You asked the Plan to pre-approve TheraSkin. The Plan denied your request. The Plan says TheraSkin is not 
medically necessary and does not meet the Medicare LCD criteria. 
 
The Plan follows Medicare 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 pre-approve TheraSkin. Our reviewer says that the 
requested TheraSkin is not medically necessary. Our physician reviewer found based on the provided 
documentation, the current treatment regimen is improving the wound quite significantly already and should be 
continued. There was objective information provided suggesting failure of current treatment to support 
TheraSkin use at this time. Therefore, this request for such will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TheraSkin.