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

We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pay for LDCT scan. You say that this test was medically necessary, and you were not aware that he needed prior authorization. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because you did not meet the Medicare criteria for LDCT lung cancer screening and authorization was not obtained for this test.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria.

We reviewed the file and the Medicare rules. We find that you quit smoking more than 15 years ago. Therefore, we decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell injections.

You asked the Plan to pre-approve stem cell injections. You say that your knee arthritis has not been controlled by conservative measures and this procedure is necessary. The Plan denied your request. The Plan says this is not a covered service for your 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 stem cell injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Stem cell treatment for knee pain and degenerative joint disease remains experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stem cell injection have not been met. Therefore, we decided that the Plan does not have to pre-approve stem cell injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio, 9 injections, 300 mg.

You asked the Plan to pre-approve Entyvio. You say that the injections are medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs, Remicade or Inflectra, and Stelara. The Plan says there is no indication the preferred drug would likely be less effective, and/or cause adverse effects for the enrollee.

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 Entyvio. Our reviewer says that the requested Entyvio injections are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs. The reviewer also found that there is no indication 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio, 9 injections, 300 mg.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for surgical treatment of a ruptured duodenal ulcer, kidney insufficiency and fluid overload. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60mg Dexilant.

You asked the Plan to pre-approve the Dexilant. You say that you would like reconsideration because this medication is medically necessary. The Plan denied your request. The Plan says this medication does not fall under Medicare Part B.

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 60mg Dexilant.

Benefits for the Dexilant 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for peritonitis and had surgery for perforated intestine. Your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to the doctor.

You asked the Plan to pre-approve routine transportation to the doctor. You say that you would like the Plan to cover this transportation. The Plan denied your request. The Plan says this is not a covered benefit because it is not for continued acute care after discharge from an emergency room.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation to the doctor have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation to the doctor.
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 does meet LTACH criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.

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 receiving appropriate care at the present acute care hospital. There are no services available at the LTACH which the enrollee requires that are not available at the health care setting being offered by the Plan. 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 you are a 74-year-old male who was admitted to an acute care hospital. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 health plan.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty.

You asked the Plan to pre-approve a kyphoplasty. You say that this procedure is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says because the compression fracture is more
than six weeks old this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the kyphoplasty is subject to the criteria listed 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 a kyphoplasty. Our reviewer says that
the requested procedure does not satisfy Medicare criteria. Our physician reviewer found the enrollee is a 67-
year-old male was being treated for plausible age-related osteoporosis with apparent pathological fracture,
vertebrae. In this case, detailed documentation is not evident regarding pain rating utilizing the Numeric Rating
Scale [NRS] or Visual Analog Scale [VAS]. Furthermore, an updated MRI is not provided, as the provided
MRI was performed greater than 30 days prior to the request. Detailed discussion of daily functional deficit and
of kyphotic deformity are also not evident. In addition, the fracture appears to be chronic and greater than 6
months old. There is a lack of evidence of steroid-induced compressions fracture and/or any need for relative
vertebral stabilization prior to an invasive surgical procedure. Extenuating circumstances and/or rationale that
would support an exception to (the unmet) LCD are not evident.

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 kyphoplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve a kyphoplasty.
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 enrollee needs daily medical management to
return to her maximum function. The Plan denied your request. The Plan says the denial of authorization for
IRF service is correct.

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. While the
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive
rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9944).

You asked the Plan to pre-approve the occlusal guard. You say that this item is medically necessary. The Plan denied your request. The Plan says this is not a covered service under your supplemental benefit.

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. 

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 pre-approve the occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.

You asked the Plan to pre-approve Injectafer. You say that you would like this drug covered. The Plan denied
your request. The Plan says the provider has prescribed a different medication.

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 the item is
medically necessary.

We looked at the file and Medicare rules. Specifically, there were no medical records provided in this case.
Without the medical records, we cannot review to see if the services were medically necessary. Based on this
information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we
decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin 200 unit.

You asked the Plan to pre-approve Xeomin. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Xeomin is not approved for enrollee's medical condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Xeomin. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the patient is a 64-year-old female who was diagnosed with Raynaud's syndrome without gangrene, scleroderma, and systemic sclerosis. Xeomin has been requested for their condition. Xeomin is not FDA-approved for the enrollee's diagnoses. In addition, the Medicare-approved compendia do not discuss the use of Xeomin for the enrollee's conditions.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xeomin have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin 200 unit.
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 would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was admitted for syncope and was diagnosed with non-ST segment
elevation myocardial infarction (NSTEMI). The enrollee's medical problems are stable. The documentation
does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation
therapy program. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS).

You asked the Plan to pre-approve magnetic resonance spectroscopy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that MRS is non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of magnetic resonance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0108), and
wheelchair accessory (crutch and cane holder) (CPT Code E22070) to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the DME. You say that there is not a local supplier. The Plan denied your
request. The Plan says there is an in-network DME provider readily available and accessible to you.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the power wheelchair (CPT code K0108), and wheelchair accessory (crutch and cane holder) (CPT Code
E22070) to be provided by an out-of-network provider.