Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan 
denied your request. The Plan says the services the enrollee needs could be provided in another setting such as 
an acute rehabilitation facility, skilled nursing facility, outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 IRF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for IRF care 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 that on review of the available records, the enrollee with left hip fracture status post 
surgery does not meet Medicare coverage criteria for IRF admission. The enrollee is medically stable with no 
new or acute medical problems and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. At the current functional level as described above, the enrollee does not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. IRF admission is not medically necessary based on medical stability and lack of medical 
complexity. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs 
can be met safely and provided at a lower intensity and alternate setting such as in an SNFs. 
 
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 transcervical radiofrequency uterine fibroid ablation 
services. 
 
You asked the Plan to pre-approve transcervical radiofrequency uterine fibroid ablation services. You say that 
this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested procedure is considered experimental/investigational for 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 transcervical radiofrequency uterine 
fibroid ablation services. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the reviewed literature indicates that for 
individuals who have uterine fibroids who receive transcervical sonography-guided radiofrequency ablation 
(RFA) using Sonata, the evidence includes single-arm studies, the largest of which reported 3-year outcomes. 
Although the three-year outcome data reported significantly improved symptom severity scores, comparative 
effectiveness data for this type of treatment has not been published, and randomized controlled trials with 
larger patient populations are needed to adequately evaluate the long term efficacy of this technology. The 
review has determined that the items/services at issue in this case are not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcervical radiofrequency uterine fibroid ablation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transcervical radiofrequency uterine fibroid 
ablation services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis. 
 
You asked the Plan to pre-approve CT of the abdomen and pelvis. You say that the requested CT scan is 
medically necessary. The Plan denied your request. The Plan says the enrollee had a CT of the abdomen and 
pelvis perform on May 13, 2022. The Plan says that there is no documentation or clinical information to 
support duplication of the requested exam. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT of the abdomen and pelvis. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee had a 
surveillance CT of the abdomen and pelvis done on May 13, 2022, which was compared to prior exams of 
April 29, 2021, and November 2, 2021.  The reason for the repeat CT of the abdomen and pelvis so close to the 
exam of May 13, 2022, has not been explained in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. 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. Medicare rules say that CT scans 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 a CT scan of the chest. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in the letter of appeal the 
requesting physician explained that the CT of November 9, 2021 revealed a thyroid mass and afollowup 
assessment is needed. This letter failed to mention the CT done on May 31, 2022, the report of which is in the 
records submitted. It appears the requesting physician was not aware that the CT had been done on May 31, 
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 a CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Besremi. 
 
You asked the Plan to pre-approve Besremi. You say that the requested drug will be given in an infusion center 
setting. The Plan denied your request. The Plan says the requested drug is self-injectable and does not meet the 
criteria to be covered under the enrollee's Part B benefit. 
 
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 Besremi. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of chronic 
myeloid leukemia (CML.) Besremi is FDA approved for the treatment of polycythemia vera and not CML. 
Off-label use is not supported for CML by major drug compendia or the medical literature. Other forms of 
inteferon are approved for CML. The requested drug is 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 Besremi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Besremi.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Capecitabine. 
 
You asked the Plan to pre-approve Capecitabine. You say that the requested drug is medically necessary for 
treatment of the enrollee's cancer. The Plan denied your request. The Plan says the use of the requested 
drug/regimen is not reasonable and 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 Capecitabine. 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 hormone receptor-positive, HER2 positive refractory metastatic breast 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 Capecitabine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Capecitabine.
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 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the 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.
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care 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 that on review of available records, the enrollee with a cerebrovascular accident 
(CVA) with mild right lower extremity weakness does not meet the coverage criteria for an IRF admission. 
The enrollee is medically stable and does not need physical medicine and rehabilitation (PM&R) physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. At 
current high functional level, the enrollee does not require 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. The lack of complexity of the enrollee's medical condition and lack of nursing 
needs, and high functional level do not support an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitation care. The enrollee's rehab needs can be provided in an alternate and low intensity 
setting such as in home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. 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 PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) 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 percutaneous vertebral augmentation. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no 
imaging study show that the T12 fracture is acute and less than 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
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 IRF care is medically reasonable and 
necessary. The Plan denied your request. The Plan says rules for IRF care 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 that on review of the available records, you have had a left cerebrovascular accident. 
You are medically stable with no new or acute medical problems and does not need physical medicine and 
rehabilitation (PM&R) physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your level of function, you do not need 
intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. You will not tolerate the intensity of IRF. IRF admission is not medically 
necessary based on medical stability and lack of medical complexity and independent functional mobility. 
Document does not support the medical necessity for admission to an IRF. While you may benefit from 
physical therapy and occupational therapy, your rehab needs can be met safely and provided at a lower 
intensity and alternate setting such as in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 a partial mastectomy. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee has recurrent breast cancer/a polyp 
growth that can turn into cancer and has to be removed immediately. The Plan denied your request. The Plan 
says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation does not support that a partial mastectomy is medically reasonable 
and necessary for the enrollee in this case. The enrollee was evaluated on May 26, 2022 and was noted to have 
a 1cm mass in the right breast. There is no documented tenderness or change in size. There is no documentation 
of a biopsy. An ultrasound on 2/1/22 revealed a likely sebaceous cyst which was stable and probably benign. A 
repeat ultrasound and routine self breast exams with annual follow up were recommended by the enrollee's 
physician. The enrollee expressed that she wanted the lesion excised. 
  
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a partial mastectomy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec. 
 
You asked the Plan to pre-approve Nurtec. You say that the enrollee has been clinical stable while taking 
Nurtec. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit under this 
contract. The Plan says that the enrollee does have Verizon which provides its own pharmacy benefits. 
 
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 Nurtec.  
 
Benefits for Nurtec 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport, basic life support 
(A0428), and ground mileage (A0425) provided on December 28, 2021. 
 
You asked the Plan to pay for the services. You say that the ambulance services were medically necessary for 
oxygen monitoring. The Plan denied your request. The Plan says the ambulance services were not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that the patient needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport on  December 28, 2021. The patient was discharged from an Emergency Department after treatment for a displaced G tube. Vital 
signs were stable and there was no documented medical need for BLS or ALS services. The documentation 
does not support that the ambulance transport on December 28, 2021 was medically reasonable and necessary 
for the patient. 
 
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 pay for the non-emergency ambulance transport, basic life support (A0428), and ground mileage 
(A0425) provided on December 28, 2021.