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 the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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 can be 
provided in a lower level of care. The enrollee requires treatment by multiple therapies, including physical and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at a lower level of 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 Tecentriq (J9022), dexamethasone sodium phosphate 
(J1100), cisplatin (J9060) and irinotecan (J9206). 
 
You asked the Plan to pre-approve the requested drugs. You say that the requested regimen is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested use of this drug 
combination is not supported. 
 
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 the requested drugs. Our reviewer says 
that the requested drug combination is not supported. Our physician reviewer found the enrollee has extensive 
stage small cell lung cancer. The enrollee was diagnosed with limited small cell lung cancer and started 
chemotherapy on January 17, 2023 with carboplatin and etoposide and completed four cycles of chemotherapy. 
Signs of recurrence in the liver were first noted in August, 2023. The Food and Drug Administration has not 
stated that the requested drug regimen is indicated for the enrollee's specific condition. The requested use is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal.  
 
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 requested drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Tecentriq (J9022), dexamethasone sodium phosphate (J1100), cisplatin (J9060) and 
irinotecan (J9206).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs the device due to 
worsening heart failure. The Plan denied your request. The Plan says there is not enough evidence the device 
would improve the outcome of 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 the requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure. The clinical study on which the Food 
and Drug Administration (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 enrollees 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF services are necessary because 
the enrollee does not have help at home. You also say the enrollee has no telephone or cell phone to 
communicate if something happens. The Plan denied your request. The Plan says admission to a SNF is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that the items should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly 
as you do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
 
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 automatic blood pressure monitor. 
Our physician reviewer found that the record does not indicate the enrollees office blood pressure greater than 
140/90 on at least three separate visits with two separate measurements made each visit. The records do not 
include at least two documented blood pressure measurements taken outside of the office which are greater 
than 140/90. The records do not show evidence of end-organ damage. 
 
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 automatic blood pressure monitor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
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 aggressive therapy to gain function of your 
leg. The Plan denied your request. The Plan says your condition does not meet Medicare guidelines for 
admission to an IRF.  
 
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 clinical documentation does not specify any active medical comorbidities. Thus, 
the complexity of 
your documented nursing, medical, and rehabilitation needs would not be expected to require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical documentation shows that 
you would be expected to require ongoing physical therapy and occupational therapy but does not support the 
medical necessity of an intensive rehabilitation regimen in an IRF 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional visits are necessary. The 
Plan denied your request. The Plan says the additional visits are not reasonable or necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has been receiving physical therapy since April 25, 2023. 
The enrollee has no limitation with mobility or performing basic daily activities and is physically active. The 
enrollee is performing dynamic strengthening exercises, and this can be done with a home exercise program. 
Therefore, the 15 additional PT visits are 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional physical therapy (PT) visits.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. You asked the Plan to pre-approve Eylea. You 
say that the recommended alternative, Avastin, is not an FDA-approved medication for the enrollee's specific 
diagnosis. The Plan denied your request. The Plan says the requested drug is a non-preferred product. Trial and failure of both preferred products (Avastin then Byooviz after trial/failure of Avastin) are required before the 
use of a non-preferred product (unless other exception criteria are met). 
 
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 Eylea. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the case file does not contain 
documentation of trial and failure of Avastin and Byooviz. There is insufficient documentation supporting that 
Avastin and Byooviz would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital level of care for uterine 
tandem/vaginal ovoids and pelvis needles or catheters in preparation for brachytherapy. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs this device 
inserted. The Plan denied your request. The Plan says the enrollee does not need inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this 
case. Our physician reviewer found the enrollee presented to the emergency department with fatigue since 
starting hormone therapy. Following workup and consultation surgery was not recommended and plans were 
made for outpatient Provera and radiation treatment. Vital signs were stable. The enrollee is not expected to 
require hospital care that would likely span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital level of care for uterine tandem/vaginal ovoids and 
pelvis needles or catheters in preparation for brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an SIJ injection. 
 
You asked the Plan to pre-approve a SIJ injection. You say that the requested procedure is medically necessary. 
The Plan denied your request. The Plan says the requested injections do not meet the requirements for 
approval. 
 
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 SIJ injection. 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 on physical examination of three (3) or more positive tests results. 
The clinical value and effectiveness of an SIJ injection in the absence of tenderness and negative provocative 
testing results has not been demonstrated in the peer-reviewed literature. 
 
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 SIJ injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an SIJ injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spring peripheral nerve stimulator (PNS) system. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Sprint PNS device is the subject of 
ongoing clinical trials for low back pain. It is considered experimental in nature and not 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 a Spring peripheral nerve stimulator (PNS) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. 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 the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and asthma. There is no diagnosis of bronchiectasis, cystic fibrosis, or 
neuromuscular disease.  COPD and asthma are not diagnoses for which Medicare covers the high-frequency 
chest wall oscillation device. The services are therefore 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge for teeth #3-5. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the loss 
of bone support around tooth #5 does not offer a favorable prognosis.  
 
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 requested 
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 requested services. Our physician 
reviewer found that the only radiographs provided with the documentation were bite wings. A determination of 
the quality of the bone support of tooth #5 could not be made from these radiographs. Periapical radiographs 
are required to view the entire tooth and surrounding bone. Therefore, the request is not reasonable and 
necessary at this time. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a dental bridge for teeth #3-5.