Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table.
You asked the Plan to pre-approve the table. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested item does not appear to be a Medicare item.
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 table. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found a review of the literature does not indicates that the requested inverter table is medically necessary for
your condition. The literature does not indicate that this device is safe or effective. An AHRQ comparative
effectiveness study reported that traction was not effective or was associated with only very small effects. A
Cochrane systematic review of traction for low back pain with or without sciatica concluded that traction,
either alone or in combination with other treatments, had little or no impact on pain intensity, functional status,
global improvement, and return to work. A review of a the literature reveals there are contraindications to
cervical traction and the patient must have a detailed neuromuscular and complete physical exam to ensure no
contraindications to using this inversion device prior to use and observe for adverse effects after use. The
documentation does not reveal that you have had a thorough neuromuscular exam or complete evaluation of
possible contraindications prior to the use of this device from the recommending provider.
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 table have not been met. Therefore, we decided that the Plan does not have
to pre-approve an inversion table.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve repair of eyelid and brow defect for the enrollee. You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your request. The Plan says that the information does not comply with the rules established by Medicare. The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the repair. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the criteria was met based on the history, physical exam, and photographs. Medicare criteria specify that records should contain "complaint(s) that the patient has about their ability to see or function". The LCD requires the visual fields "should demonstrate a minimum 12 degree or 30 percent loss of upper field of vision with upper skin and/or upper lid margin taped and untaped." The visual fields clearly demonstrate the superior defect, but without the required minimum improvement. Due to the enrollee's poor elevator function and history of muscular dystrophy, the visual field tests are not reliable and should not be used to determine medical necessity. Photographs demonstrate ptosis that supports the visual field results and the patient complaints. There is compelling evidence that the surgery is 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 repair have been met. Therefore, we decided that the Plan has to pre-approve repair of eyelid and brow defect for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve surgical extraction tooth 29 (D7210).
You asked the Plan to pre-approve the dental services. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says that the documentation submitted does not support that surgical techniques would be necessary for tooth removal. A less severe extraction code.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found the level of the bone. The lack of thickness of dentin at or near the neck of the tooth along with the structurally non-supportive pulp chamber makes the area weak. Attempted removal of the tooth would likely result in fracture at the neck of the tooth which would necessitate bone cutting to remove the entire tooth. Given the presentation of the decay/missing structure on tooth #29 at the neck of the tooth and the high level of remaining bone it appears reasonable to consider D7210 as the proper code for the extraction of this tooth. 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 been met. Therefore, we decided that the Plan has to pre-approve surgical extraction tooth 29 (D7210).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic for the enrollee under Medicare Part B.
You asked the Plan to pre-approve self-administered drugs under Medicare Part B. You say that this drug is
medically necessary. The Plan denied your request. The Plan says this drug is not covered under Medicare Part
B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ozempic for the enrollee
under Medicare Part B.
Benefits for self-administered drugs 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: 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 clinical documentation supports the request for LTACH care. The Plan denied your request. The Plan says the records do not show that LTACH care is medically necessary.
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 is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest. The enrollee has been intubated/ventilated since presentation. The enrollee is noted to have hypoxic encephalopathy and persistent seizures. The enrollee is described as being in a vegetative state and having a poor prognosis. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there is
no advantage in moving the enrollee from the current acute care hospital to an LTACH.
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 physician
reviewer found that the enrollee was admitted to the acute care hospital with respiratory failure. LTACHs are
certified as acute care hospitals, and in general, do not provide clinical services that are materially different
than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care
services have not been denied. The documentation does not support that the enrollee in this case requires
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The
documentation does not support that 25 days or more of continued acute care are reasonably expected. There
are no required medical services identified that are available at the LTACH, that are not available at the current
health care setting being offered by the health plan. Consequently, the requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission 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 based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to be able to perform fifteen hours per week of rehabilitative services. 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-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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that intensive PT and OT are needed to maximize
function, safety and independence with mobility and ADL's. The Plan denied your request. The Plan says that
the enrollee 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 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that based on the medical records provided, the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services
but based on the medical records provided the patient does not require an intensive inpatient rehabilitation
therapy program. Based on the medical records provided there is concern that the enrollee will not be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat medial branch block facet injections at L3-L4
and L5.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says facet injections must be done fluoroscopy or CT guidance, not ultrasound
guidance, which is investigational.
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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the failure of the first set of diagnostic medial branch blocks means the test is negative. It
should not be repeated. Clearly, alternative pain generators are present. The requested procedure 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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve repeat medial branch block facet injections at L3-L4 and L5.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage under the Medicare Part A benefit.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. You say that you want the enrollee treated with this drug. The Plan
denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to
Neupogen and Nivestym.
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 Zarxio. Our reviewer says that the drug
is not medically reasonable and necessary. Our physician reviewer found based on the documentation provided
the health plan's denial should be upheld. While the documentation notes a plan to use Neupogen, a request was
made for Zarxio. The health plan requires that Neupogen or Nivestym be used. There is no evidence that the
enrollee is allergic to or intolerant of these other drugs. There is no evidence that the enrollee has tried and not
responded to these other drugs. There is no documentation as to why these other drugs would not be expected
to be safe and effective for the enrollee. Therefore, the requested Zarxio is not shown to be currently medically
necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zarxio.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service provided on November 21, 2019.
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim copayment. The Plan denied your request. The Plan says this claim is a duplicate of a paid claim.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. Medicare rules say that providers must report services correctly. The Plan follows the same rules. We looked at the file and Medicare rules. There is no documentation that this claim is not a duplicate of the paid claim. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 12, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for laboratory services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that no one told you that the provider was a nurse practitioner.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kanjinti (Q5117). You asked the Plan to pre-approve Kanjinti. You say that you need this medication. The Plan denied your request. The Plan says this drug is not supported for your diagnosis.
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 Kanjinti. Our reviewer says that the criteria for Kanjinti have not been met. Our physician reviewer found the requested use of Kanjinti is not FDA-approved as monotherapy for the your diagnosis. The monotherapy use is not supported by the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is no data to support the use of trastuzumab plus endocrine therapy (without prior use of chemotherapy) for women with estrogen receptor (ER)-positive, HER2-positive breast cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kanjinti have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti (Q5117).