Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional occupational therapy.You asked the Plan to pre-approveadditional occupational therapy. Yousay that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessaryoutpatient 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 additional occupational therapy. Our reviewer says thatskilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you required maximum assistance with lower body dressing and toileting. You have had prior therapy forthis condition and the documentation does not indicate that your functional level requires the ongoing additional therapy with the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The plan has approved additional therapy which can be used to review a home exercise program. Therefore, you do not meet criteria for the requested occupational therapy 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 additional occupational therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional occupational therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with a computerized knee, and additional components for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee meets the definition of a functional level 3 amputee per the guidelines. The Plan denied your request. The Plan says this request does not meet the criteria as reasonable or 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items L5828, L5845, L5848, L5856 exceed the enrollee's medical need as the documentation of ambulation with a walker and crutches and for long distances utilizing a wheelchair to reduce strain on his osteoarthritic right knee does not support that this enrollee is a K3 ambulator. 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 pre-approve a prosthetic leg with a computerized knee, and additional components for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevaricose vein treatment for the enrollee.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documentation indicating symptomatic varicose veins, with significant pain or swelling interfering with ADLs.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary inthis case. Our physician reviewer found the documentation does not meet coverage criteria and does not support the medical necessity of the procedure in question. Specifically, the enrollee does not describe significant symptoms attributable to the 
varicose veins that interfere with daily activities or mobility. The enrollee is status post accessory saphenous ablation and phlebectomy. The materials provided do not document absence of saphenous vein reflux. The documentation does not support that the veins in question are greater than 4 mm in diameter. There is no evidence of concerted efforts at conservative therapy for the enrollee's current concerns.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approvevaricose vein treatment for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity ofservices provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation.  The enrollee's care needs can be met 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dynasplintshoulder flex device.You asked the Plan to pre-approvea Dynasplint shoulder flex device. You say that the requested Dynasplint shoulder flex device is medically necessary.The Plan denied your request. The Plan says the requested Dynasplint shoulder flex device 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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Dynasplint shoulder flex device. Our reviewer says that the requested Dynasplint shoulder flex device is not medically necessary. Our physician reviewer found the documentation does not support that the Dynasplint is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not support that this device issafe and effective for this enrollee's condition.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 Dynasplint shoulder flex device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dynasplint shoulder flex device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of SNF care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not have complex wound care, new enteralfeedings or other skilled nursing needs that requires a SNF stay beyond the last covered date. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF beyond the last covered date. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting beyond the last covered date.
Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple power options for a power wheelchair. You asked the Plan to pre-approve the accessories. 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 the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2377 Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function are sufficient to control any power options through their own switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple power options for a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSkilled Nursing Facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that the SNF services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care, at the time of diagnosis with COVID-19. The enrollee did not have any parenteral medication, complex wound care, or nutrition given via a feeding tube. She was medically stable without any acute exacerbations of chronic medical problems. Her physical function was at or near her baseline and she could have received further services 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveSkilled Nursing Facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a ClariFix procedure.
You asked the Plan to pre-approve a ClariFix procedure. You say that the requested ClariFix procedure is
medically necessary. The Plan denied your request. The Plan says that the requested ClariFix procedure is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 ClariFix procedure. Our reviewer says
that the requested ClariFix procedure is medically necessary. Our physician reviewer found the enrollee has a
history of suffering from rhinitis. She appears to have both an allergic and a vasomotor component given that
she improved with both Flonase and Atrovent. Treatment for vasomotor rhinitis can include continuing
Atrovent nasal spray, a vidian neurectomy, or the most recent option is the ClariFix procedure. The ClariFix
procedure is unique in that it is a cryoablation of the vidian nerve, thereby treating the vasomotor rhinitis
without requiring permanent transection of the nerve. The literature supporting the use of ClariFix is limited
due to it being a new procedure. However, it has been shown to improve the symptoms of vasomotor rhinitis.
The article "cryosurgical posterior nasal tissue ablation for the treatment of rhinitis" published in 2017 states
both rhinorrhea and congestion decreased significantly at 30, 90, 180, and 365 days compared to baseline.
Interestingly, allergic and nonallergic subcohorts both improved with treatment. Based on this enrollee's history
and her symptoms, she would likely benefit from the procedure.
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 ClariFix procedure have been met. Therefore, we decided that the Plan has to
pre-approve a ClariFix procedure.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lurbinectedin, Dexamethasone Sodium Phosphate,
Palonosetron HCL for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no NCCN or Medicare approved literature support for continuation of the
requested regime after progression of disease.
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 drugs. Our reviewer says that the
requested drugs are not medically reasonable or necessary. Our physician reviewer found the documentation
shows progression of disease while on Lurbinectedin. Per the documentation, the enrollee has been receiving
Lurbinectedin for extensive stage small cell lung cancer since 11/2020. CT scan from 1/7/2021 shows
progression changes since the 10/22/2020 scan with increasing size in right adrenal gland mass and new left
lower lobe nodule. There is no NCCN or Medicare approved literature support for continuation of the requested
regime after progression of 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 the drugs have not been met. Therefore, we decided that the Plan does not have
to pre-approve Lurbinectedin, Dexamethasone Sodium Phosphate, Palonosetron HCL for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH 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 LTACH services are covered if they are medicallynecessary, 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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the records show that you are currently receiving treatment in the acute care hospital (ACH) for COVID-19. You are no longer intubated/ventilated. There is no evidence that you require services at the LTACH that are not available at the current ACH. The LTACH services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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
enrollee does not meet criteria for IRF admission. 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 respiratory failure and COVID-
19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There
are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for
physical and occupational therapy, it does not document a need for an intensive rehabilitation program.
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-approvea right Unilateral medical knee joint surgery (CPT Code(s): 29880, 29882, 29881).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says your records do not show that the enrollee failed to improve following a trial of at least three (3) months of treatment directed by their doctor. The  Plan states the requested knee surgery is not supported prior to a trial of treatment for at least 3 months.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 services. Our reviewer says that the requested items/services are not considered medicallyreasonable and necessary in this case. Our physician reviewer found the supplied documentation also does not evidence recurrent mechanical locking or catching of the right knee nor is there documentation of the knee recurrently giving way/instability. Therefore, the request for the removal of both knee cartilages using an endoscope (29880), Removal of one knee cartilage using an endoscope (29881), repair of knee joint using an endoscope (29882) is 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 the services have not been met.Therefore, we decided that the Plan does not have to pre-approvea right Unilateral medical knee joint surgery (CPT Code(s): 29880, 29882, 29881)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePRALUENT.You asked the Plan to pre-approvePRALUENT. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the requested drug is not a covered benefit.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-approvePRALUENT.Benefits for PRALUENTmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights