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

 
We decided that the Plan does not have to pre-approve Keytruda, pemetrexed, and carboplatin.  
 
You asked the Plan to pre-approve Keytruda, pemetrexed, and carboplatin. You say that given the enrollee's 
long disease and treatment history and their favorable response and tolerability to this regimen, you 
recommend the enrollee restart therapy with this regimen.  The Plan denied your request. The Plan says 
medical studies have not proven that the requested drugs are helpful when the enrollee has already tried 
Keytruda and did not have a positive response.  
 
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, pemetrexed, and carboplatin. Our reviewer says that the requested drugs are not medically necessary. Our physician reviewer found the 
requested use of Keytruda, pemetrexed, and carboplatin is not FDA-approved for the enrollees diagnosis. The 
use of Keytruda, pemetrexed, and carboplatin is not supported by one of the major drug compendia or by 
clinical research that appears in a Medicare-approved medical journal.  
 
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, pemetrexed, and carboplatin.  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Keytruda, pemetrexed, and carboplatin.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daratumumab. 
 
You asked the Plan to pre-approve daratumumab. You say that the patient had more side effects using 
Revlimid and the use of daratumumab is medically necessary to treat the diagnosis of multiple myeloma. The 
Plan denied your request. The Plan says the criteria for coverage have 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 daratumumab. Our reviewer says that 
the requested drug cannot be recommended. Our physician reviewer found the enrollee has a diagnosis of 
multiple myeloma and is not documented to be a transplant candidate. The enrollee is receiving the requested 
medication as maintenance monotherapy; however, the FDA has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare approved cancer drug compendia does not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daratumumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve daratumumab.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of a prostate rectal spacer (SpaceOAR) 
(55874). 
 You asked the Plan to pre-approve the placement of a prostate rectal spacer. You say that the enrollee is an 
excellent candidate for Spacer Gel placement. The Plan denied your request. The Plan says Medicare criteria 
are not met therefore, the denial is upheld based on lack of medical necessity for the service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that Polyethylene-glycol (PEG) hydrogel is covered once in patients 
with clinically localized prostate cancer who meet specific coverage criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the placement of a prostate rectal 
spacer. 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 the enrollee meets 
coverage criteria for the prostate rectal spacer. The provided records in this case do not document the enrollee 
has low or favorable intermediate risk prostate cancer or that the enrollee has a prostate volume of 80 cubic 
centimeters or less as required by the LCD. There is no support that the prostate rectal spacer (SpaceOAR) at 
issue in this case meets all Medicare criteria for medically reasonable and 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 the placement of a prostate rectal spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the placement of a prostate rectal spacer (SpaceOAR) 
(55874).
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 IRF care is medically necessary and not going to 
the IRF will seriously jeopardize your ability to regain maximum function. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and the your needs can be met at a lower level of care such 
as a skilled nursing facility.  
 
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 you were admitted for altered mental status. You medical problems are stable, and 
there are no complex nursing or rehabilitation needs. You do 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.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from August 18, 2023, to 
September 16, 2023. 
 
You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says a Notice of Admission (NOA) was not submitted to support this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. A Notice of Admission (NOA) was not submitted to the Plan for 
review. The Plan requested this document, but it was not submitted. As no NOA has been submitted, it cannot 
be said that the NOA was submitted within the timely limit of 5 calendar days from the start of care date. Based 
on this information, we decided that there is insufficient information in the record to determine if Medicare 
rules for coverage of home health care have been met. . Therefore, we decided that the Plan does not have to 
pay for home health care provided from August 18, 2023, to September 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that based on the enrollee's current care needs 
they can be expected to benefit from and improve with LTACH services with an expected length of stay greater 
than 25 days. The Plan denied your request. The Plan says with additional time in the current setting, clinical 
stability can be ensured such that the appropriate lower level of care can be determined. 
 
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 enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary 
as it would not be clinically advantageous. Completion of treatment at the current facility is 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sulfasalazine. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary to 
treat the enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 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 Sulfasalazine.  
 
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator. You say that you were in the hospital and tried a vent, 
this was the only thing that worked. The Plan denied your request. The Plan says you do not meet criteria for 
approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD with chronic 
respiratory failure. You did not fail BIPAP therapy or require escalation of interventions. Tolerated and treated 
with standard therapies, including BIPAP. Your documentation does not support home ventilator at this 
junction of your disease. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Beovu. 
 
You asked the Plan to pre-approve Beovu. You say that the requested Beovu is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Avastin or Byooviz first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Beovu. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has exudative age-related macular degeneration with active choroidal neovascularization. The 
requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed 
the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to 
or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Beovu have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Beovu.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Watchman LAAC procedure (33340). 
 
You asked the Plan to pre-approve a Watchman LAAC procedure. You say that the requested service is a 
medical necessity for the enrollee. 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 a Watchman LAAC procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of an evidence-based shared decision-making 
interaction on anticoagulation. Guidelines would not support implantation of a LAAC in this 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 a Watchman LAAC procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Watchman LAAC procedure (33340).
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 enrollee exceeds the CMS criteria for 
an LTACH appropriate admission. The Plan denied your request. The Plan says the request for LTACH 
services to be covered does not meet the requirements for approval. 
 
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 record does not support that an LTACH would provide additional services 
that the acute care hospital cannot. 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 Plan. The enrollee does not require complex 
wound care, ventilatory support or other complex support. The enrollees intravenous antibiotics are scheduled 
to finish on February 1, 2024. The record does not support that the enrollee will require prolonged 
hospitalization of 25 days or more. 
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve the drug. You say that this si medically necessary. The Plan denied your 
request. The Plan says the enrollee has not medically failed Praluent, and the enrollee has not tried Repatha. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of drugs of Repatha or Praluent before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drugs. There is no documentation provided indicating that the plan's required 
drugs would likely be less effective and/or likely have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the saving's plan provided on June 28, 2023. 
 
You asked the Plan to reimburse for the saving's plan. You say that the provider sells you a savings package 
each year. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse for the 
saving's plan provided on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the irreversible electroporation. 
 
You asked the Plan to pre-approve the irreversible electroporation. You say that irreversible electroporation 
offers the best clinical opportunity for improvement of the patient's condition. The Plan denied your request. 
The Plan says more research is needed to show the safety and efficacy of this procedure. 
 
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 irreversible electroporation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has intermediate risk prostate cancer. There is insufficient 
literature to support the safety and efficacy of the requested service. Therefore, the elements of the coverage 
criteria are not satisfied, and the requested service is not 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 irreversible electroporation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the irreversible electroporation.
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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 knee replacement surgery. 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.