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

We decided that the Plan has to pre-approve use of GenVisc.
You asked the Plan to pre-approve GenVisc. You say that your knee has pain, osteoarthritis, and instability and GenVisc is the next approach to help you. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because you have not completed 6 weeks of physical therapy.
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 GenVisc. Our reviewer says that you meet the Medicare criteria for the requested use of GenVisc. Our physician reviewer found a Medicare-approved drug compendium states that hyaluronic acid (such as GenVisc) is indicated for osteoarthritis pain in patients who have not responded to conservative non-pharmacologic therapy or to simple pain relievers such as acetaminophen. In this case, the record indicates that you have failed conservative therapy for treatment of your knee osteoarthritis. Therefore, the requested use of GenVisc is medically reasonable and 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 GenVisc have been met. Therefore, we decided that the Plan has to pre-approve use of GenVisc.
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 Repatha 140 mg/ml injection.
You asked the Plan to pre-approve Repatha. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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-approve Repatha 140 mg/ml injection.
Benefits for Repatha 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 pay for the elective right total hip arthroplasty after care to be
performed inpatient.

You asked the Plan to pay for acute inpatient hospital care after surgery. You say that the enrollee is at a high
risk for complication of co-morbidity that warrant an inpatient stay after surgery. The Plan denied your request. The Plan says hip replacement surgery is not listed as an inpatient procedure. After surgery care can be done in
an observation setting.

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 pay for acute inpatient hospital care after surgery.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that there is no significant medical history or documented expected
complications or significant risks associated with this procedure that would likely require inpatient services that
would cross 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 pay for an elective right total hip arthroplasty after care to be performed inpatient.
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 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 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 medically necessary. Our physician reviewer found the enrollee was readmitted to the hospital following cardiac surgery with acute respiratory failure, heart exacerbation, infected wounds, and acute kidney failure. The enrollee is receiving acute care services that have not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving but would be available at the LTACH. The 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-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 admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for acute respiratory failure and a hemorrhagic pleural effusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
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 are not able to go home due to your current condition and are in need of rehabilitation services. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility or sub-acute rehabilitation. 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 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 the enrollee is receiving appropriate inpatient acute care and does not require transfer.
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 hospital after a bike accident. He suffered a left fibula fracture and acute respiratory failure. The enrollee is receiving appropriate care at the present acute care hospital. He does 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 he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing X-ray - four films (D0274) received November 29, 2020.
You asked the Plan to pay for the dental services. You say that the requested services were necessary. The Plan denied your request. The Plan says you have a $500 maximum benefit allowance for covered routine dental services.
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 payment for these items or services are in excess of that covered under this benefit. The Plan has submitted evidence that you exhausted your $500 allowance prior to this date of service. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the bitewing X-ray - four films (D0274) received November 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound repair rendered on November 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 12031 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 12031 and 29125. Code 12031 is a column II code with a modifier indicator of 1 when billed with column I code 29125. Code 12031 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the wound repair rendered on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K3 prosthesis with microprocessor knee.
You asked the Plan to pre-approve K3 prosthesis with microprocessor knee. You say that please review the re-submitted documentation. The Plan denied your request. The Plan says the K3 prostheses with microprocessor knee and the two L5984 ankles exceeds the enrollee's need and does not meet Medicare criteria as reasonable and 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 K3 prosthesis with microprocessor knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested K3 prosthesis with microprocessor knee is not supported by the physician progress notes and exceeds patient's functional need and does not meet Medicare criteria as reasonable and necessary. The enrollee uses a cane, crutches, wheelchair has a disability placard all of which do not support a K3 ambulatory level as this exceeds his medical/functional need. The requested two L5984 also exceed the patient's functional need and 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 K3 prosthesis with microprocessor knee have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 prosthesis with microprocessor knee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond May 9, 2020.
You asked the Plan to pre-approve SNF care. You say that you need continued care for antibiotics and wound care. The Plan denied your request. The Plan says you no longer need this level of care.
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 daily skilled services are not necessary. Our physician reviewer found the record shows that your wound care is not complex and your IV antibiotics do not require a skilled nursing SNF level of admission and can be performed at a custodial level. Your functional level does not require skilled therapy services. Skilled nursing or therapy services are not required on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
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 skilled nursing facility (SNF) care beyond May 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of May 10, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are still in the hospital and need approval for a lengthier stay. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is correct, because you no longer meet criteria for inpatient level of care and can be treated in a lower level of care such as outpatient.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that you do not meet the Medicare criteria for continued inpatient psychiatric care as on May 10, 2021. Our physician reviewer found it is not expected that you would improve in a reasonable period of time beyond the date in question as you were not showing any dangerousness to self or others, but questionable auditory and visual hallucinations. You were not showing any aggressive behaviors or acute threats to safety. You were cooperative and compliant with medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregabalin.
You asked the Plan to pre-approve Pregabalin. The Plan denied your request. The Plan says this medication does not fall under 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 Pregabalin.
Benefits for Pregabalin 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 the 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 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 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan.

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that the enrollee has a diagnosis of recurrent chronic idiopathic thrombocytopenic purpura. She was treated with Rituxan in 2019 and December of 2020. The Medicare compendia do not restrict the dosing of this drug. The services are therefore safe and effective and reasonable and medically necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Rituxan.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on September 4, 2020, during an outpatient procedure.
You asked the Plan to pay for the compression device. You say that this equipment was issued for the patient for use during a surgical procedure. Neither the facility nor the prescribing physician paid for the use of these items. You feel that the plan must pay for these items. The Plan denied your request. The Plan says Medicare does not cover pneumatic compression for preventing blood clots.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item provided in this case was not provided for use in the home. It was provided for use during a surgical procedure. As such, it cannot be covered under the durable medical equipment benefit. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on September 4, 2020, during an outpatient procedure.