Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need inpatient treatment. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with stroke and dizziness. Your medical problems are now stable and you have 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. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arcalyst.

You asked the Plan to pre-approve Arcalyst. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

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 Arcalyst. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Periodic Fever Syndromes. The enrollee has a Familial Mediterranean Fever (FMF), diagnosed in late adulthood, and Anakinra was not effective and Canakinumab worked but caused severe migraines. Arcalyst is FDA approved for the treatment of a certain group of inherited disorders called cryopyrin-associated periodic syndromes (CAPS), including familial cold autoinflammatory syndrome and Muckle-Wells syndrome. The use of this medication for the treatment of FMF is not FDA approved and is not supported in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arcalyst have not been met. Therefore, we decided that the Plan does not have to pre-approve Arcalyst.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not have a diagnosis for which the services are covered.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Volara high frequency chest wall oscillation device (HFCWOD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you want to receive therapy services in the SNF and do not feel safe if you return home alone. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete maxillary and mandibular dentures.

You asked the Plan to pre-approve complete maxillary and mandibular dentures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items exceed your benefit limit.

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 complete maxillary and mandibular dentures are covered once every 60 months. 

We looked at the file and Medicare rules. Review of the file shows that you previously received dentures. Sixty (60) months have not passed since you last received dentures. Based on this information, we decided that the Plan's rules for coverage of complete maxillary and mandibular dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve complete maxillary and mandibular dentures.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rituxan infusion, 375 mg/ml, at 4 mg/ml once per week for 4 weeks.

You asked the Plan to pre-approve the Rituxan infusion. You say that the enrollee continues to respond to therapy. You say that the requested dosage is necessary. The Plan denied your request. The Plan says the requested dosing schedule is not supported.

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 the Rituxan infusion. Our reviewer says that the requested Rituxan infusions are not medically necessary. Our physician reviewer found Rituxan is Food and Drug Administration (FDA) approved for the enrollee's diagnosis. The reviewer found that the requested dosing schedule is not approved after completion of induction dosing, which the enrollee has previously received. The reviewer found that there is no documentation that requested dosing schedule (after induction) is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that based on the medical records provided and the Medicare-approved major drug compendia the Rituxan dosing schedule requested is not certified as safe and effective and otherwise reasonable and necessary for this 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 the Rituxan infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a Rituxan infusion, 375 mg/ml, at 4 mg/ml once per week for 4 weeks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of the health problem.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of onabotulinumtoxin-A (Botox).

You asked the Plan to pre-approve Botox. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee does not have an accepted indication for onabotulinumtoxin-A.

The Plan follows Medicare rules. Medicare rules state that botulinum toxins may be covered for FDA-approved indications or certain off-label uses. 

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 Botox. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of onabotulinumtoxin-A. Our physician reviewer found the enrollee is noted to have lower extremity dystonia secondary to Parkinson's Disease. The requested medication (Botox) is not currently FDA-approved for use in this indication, nor is the medication supported for use in drug compendia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of onabotulinumtoxin-A (Botox).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.

You asked the Plan to pre-approve Restasis. You say that you would like the plan to reconsider their denial. The Plan denied 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-approve Restasis.

Benefits for Restasis 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee genicular nerve block.

You asked the Plan to pre-approve right knee genicular nerve block. 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 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 right knee genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have pain in the right knee. You have tried physical therapy, home exercise program, and chiropractic therapy. You are status post total knee replacement in 2006. The request is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, you do not meet criteria for the requested 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 right knee genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve right knee genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820)

You asked the Plan to pre-approve an interim partial denture. You say that the services are necessary. The Plan denied your request. The Plan says the partial denture is not covered under the enrollee's dental benefits.

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 an interim partial denture (D5820).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve a skilled nursing facility admission. You say that the enrollee needs further gait, balance, and endurance training. The Plan denied your request. The Plan says the enrollee does not have a condition that requires skilled nursing facility services.

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 a skilled nursing facility 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 identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 a skilled nursing facility admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has had chronic pain and has done a variety of things but the pain had increased and functionality decreased. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices remain experimental for use in spinal surgery. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for Perforomist.

You asked the Plan to reduce the cost share for Perforomist. The Plan denied your request. The Plan says products covered under the Part B benefit are not eligible for a lower copay.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 

Perforomist falls within the Medicare Part B prescription drugs benefit category. This means that a 20% coinsurance is the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the cost share for Perforomist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin tablets.

You asked the Plan to pre-approve Oxycontin tablets. You say that the enrollee has had excellent pain control on this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Oxycontin tablets.

Benefits for Oxycontin tablets 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 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 you are a 79-year-old female with elective left total reverse shoulder replacement. You did well after her surgery then per the appeal records were admitted to the intensive care unit as you were not medically stable. There are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and do 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator (E0770) and electrical stimulator supplies (A4595).

You asked the Plan to pre-approve a functional electrical stimulator and stimulator supplies. You say that this item is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this is not a covered service when the member does not have a spinal cord injury or muscle atrophy.

The Plan must follow Medicare rules. Medicare rules say that neuromuscular electrical stimulation is only covered for muscle atrophy or spinal cord injury. 

We looked at the file and Medicare rules. The file indicates that this device is being provided for the enrollee's multiple sclerosis and not for muscle atrophy or spinal cord injury. Based on this information, we decided that Medicare rules for coverage of a functional electrical stimulator and stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator (E0770) and electrical stimulator supplies (A4595).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rotator cuff repair surgery.

You asked the Plan to pre-approve rotator cuff repair surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had a course of conservative treatment, the imaging submitted is from more than 1 year ago, and the enrollee is at high risk.

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 rotator cuff repair surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial and failure of physical therapy for shoulder pain. There are no documented red flags for shoulder surgery. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of rotator cuff repair surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve rotator cuff repair surgery.