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 need therapy to learn how to walk and manage 
with having one leg. The Plan denied your request. The Plan says your medical conditions have stabilized and 
you do not need to be seen by a rehabilitation physician at least three times a week for evaluation of functional 
and medical goals and progress. The Plan says services needed  can be provided safely in other settings, a 
skilled nursing facility, home with home health services or home with outpatient therapy.  
 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. The medical records 
support a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It 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 continued hospital observation stay. 
 
You asked the Plan to pre-approve continued hospital observation stay. You say that this is medically 
necessary. The Plan denied your request. The Plan says this 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 continued hospital observation stay. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation that continued hospital observation stay was 
required after November 23, 2023. The provided records in this case document the enrollee was seizure-free 
with stable medical conditions including end stage renal disease on routine dialysis, with no need for 
medication changes per neurology and was medically stable for discharge as of November 23, 2023.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued hospital observation stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued hospital observation stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower (S5165). 
 
You asked the Plan to pre-approve a walk-in shower. You say that a walk-in shower would benefit you and 
your health. The Plan denied your request. The Plan says a walk-in shower is not primarily and customarily 
used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower (S5165).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avertix Guardian system. 
 
You asked the Plan to pre-approve Avertix Guardian system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Avertix Guardian system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the clinical studies led to FDA approval, the Avertix Guardian system remains 
the subject of studies assessing long-term efficacy, as well as randomized, controlled, blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the Avertix Guardian system would not be considered medically 
necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avertix Guardian system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Avertix Guardian system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic onlay (D2644) for tooth #14 and 
core buildups (D2950) for teeth #14 and 15. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
 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 dental services. Our physician 
reviewer found that the documentation provided in the form of radiographs and photographs did not show that 
there was significant coronal breakdown of teeth #'s 14 and 15 due to caries or fracture to warrant the requested 
services. Criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a porcelain/ceramic onlay (D2644) for tooth #14 and core buildups (D2950) for teeth 
#14 and 15.
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 requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not medically necessary.  
 
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 patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical records support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically 
necessary care can be provided in a different 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 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 the CardioMEMS HF System.  
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the CardioMEMS HF System is 
medically necessary. The Plan denied your request. The Plan says the CardioMEMS HF System 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 CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not considered medically reasonable and 
necessary. Our physician reviewer found that the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF System.
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 this course of treatment is necessary to help the 
enrollee return to his daily activities and regain his independence. The Plan denied your request. The Plan says 
based on the available information, admission to IRF is not reasonable and necessary, as the enrollee's 
condition does not meet the Medicare rules.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a transient ischemic attack. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has Gleason's grade 4+4 
adenocarcinoma of the prostate that was treated with robotic prostatectomy and radiation in 2019. He had a 
prostate specific antigen (PSA) recurrence and is on Lupron and Casodex. The use of Prolia is not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. It is only indicated for the treatment of 
bone loss in men with prostate cancer who are receiving androgen deprivation therapy (ADT). The records do 
not show that the enrollee has had bone loss or fracture. Prolia is not reasonable or medically necessary for the 
enrollee. 
 
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 Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower copayment for mycophenolate sodium. 
 
You asked the Plan to pre-approve a lower copayment for the medication. You say that you are requesting 
reconsideration for a copayment reduction. The Plan denied your request. The Plan says products covered 
under the Part B benefit are not eligible for a lower copayment. 
 
The Plan must follow Medicare rules. Medicare rules state that tiering exceptions cannot apply to Part B drugs. 
Tiering exceptions are only applicable to Part D drugs.  
 
We looked at the file and Medicare rules. The drug you are requesting is considered a Part B drug. As a result, 
no tiering exceptions can be made. Therefore, we decided that the Plan does not have to pre-approve a lower 
copayment for mycophenolate sodium.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the request is not medically necessary. Our physician reviewer found that the enrollee has a history of 
chondromalacia. Intra-articular injections of Synvisc are recommended as a possible option for severe 
osteoarthritis for patients who have not responded adequately to recommended conservative treatments. There 
is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patellae, 
osteochondritis dissecans, or patellofemoral syndrome. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
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 an ESI 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 there is no documentation of a history, 
physical examination, and diagnostic imaging to support that you have a condition for which the ESI is covered 
by Medicare. The records do not support that the criteria for coverage are met. The ESI is therefore not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel, and Dexamethsone 
sodium phosphate. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Paclitaxel, and Dexamethsone sodium phosphate. 
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 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, Carboplatin, Paclitaxel, and 
Dexamethsone sodium phosphate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested use of Keytruda, Carboplatin, Paclitaxel, and Dexamethsone sodium 
phosphate is not FDA-approved for the enrollees diagnosis. The Food and Drug Administration granted 
approval to pembrolizumab (Keytruda, Merck & Co.) in combination with chemotherapy for the treatment of 
patients with locally recurrent unresectable or metastatic triple-negative breast cancer (TNBC) whose tumors 
express programmed cell death ligand 1 (PD-L1) (Central Pain Syndrome (CPS) =10). The enrollee has a PD-
L1 CPS of 5. 
 
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, Carboplatin, Paclitaxel, and Dexamethsone sodium phosphate have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Carboplatin, 
Paclitaxel, and Dexamethsone sodium phosphate.
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 have had left sided weakness most of your life 
and now require rehabilitation in an IRF. The Plan denied your request. The Plan says the request is not 
medically necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 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.