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

We decided that the Plan does not have to pre-approveout of state physical therapy.You asked the Plan to pre-approveout of state physical therapy. You say that the medical documentation provided supports the need for the requested services.The Plan denied your request. The Plan says the enrollee does not meet the criteria for out of area coverage and should consult with her primary care physician regarding coordinating care upon her return to the network area.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 provider at issue in this case is not a network provider with the Plan. We askedour 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 out of state physical therapy. Our reviewer says that the medical documentation provided does not support the need for the requested services. Our physician reviewer found the documentation does not reveal that the requested services are urgently needed or emergent. The documentation does not reveal the PCP office visit indicating therapy is needed urgently. The enrollee has an injury 2 weeks prior to leaving the service area and his deficits could have been addressed with instruction with a home exercise program within that time period. There is no evidence that the enrollee's therapy cannot be met in network. The enrollee foresaw requiring the services prior to leaving his service area. The out of network services are not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that 
Medicare rules for coverage of out of state physical therapy have not been met. 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 out of state physical therapy.Therefore, we decided that the Plan does not have to pre-approveout of state physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), andcomplete series of intraoral x-rays (D0210) provided on October 13, 2020.You asked the Plan to pay forthe 2D oral/facial photographic image, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that you were not advisedthat these services would not be covered.The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered benefit. The Plan also says that the comprehensive oral evaluation and complete series of intraoral x-rays exceed the maximum counts allowed per period.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 2D oral/facial photographic image is not among those covered under this benefit. The contract clearly states that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and a complete series of intraoral x-rays (D0210) on August 8, 2018, and your comprehensive oral evaluation (D0150) andcomplete series of intraoral x-rays (D0210) benefits have been exhausted.Therefore, we decided that the Plan does not have to pay forthe 2D oral/facial photographic image (D0350), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care
hospitals.
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 ACH for acute respiratory failure
and chronic abdominal issues. The enrollee was transiently intubated/ventilated, but is no longer
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean admission for skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe admission. You say that home health care was tried, however there was not enough coverage.The Plandenied your request. The Plansaysthe enrollee's needs can be met safely at a lower 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 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. 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 Plandoes not haveto pre-approvean admission for skilled nursing facility (SNF) services for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are unsafe to return home without further intensive physical therapy. The Plan denied your request. The Plan says you do not require the hands-on assistance of a skilled practitioner.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you presented to the acute hospital for surgery for a right-sided colon cancer. You are unsteady with your gait. You are walking with standby assistance using a rolling walker, and are at supervision for transfer. There is no documentation that you require skilled nursing or therapy services of a skilled professional to provide medically necessary treatment. You do not require skilled services on a daily basis in a 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on April 6, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on April 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ClariFix cryotherapy.
You asked the Plan to pre-approve the cryotherapy. You say that this is medically necessary. The Plan denied
your request. The Plan says the requested procedure falls under the class of experimental and unproven.
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 cryotherapy. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found you have been diagnosed with vasomotor rhinitis. The first-line treatment for vasomotor rhinitis
is typically an anticholinergic nasal spray. The medical records do not state that you have tried this type of
nasal spray. Response to this type of nasal spray will help determine if you would benefit from the ClariFix
procedure and also support the diagnosis of vasomotor rhinitis. Without trying the first-line therapy, the
surgical procedure cannot be deemed to be medically necessary or indicated.
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 cryotherapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve ClariFix cryotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLumbar/Sacral Transforaminal Epidurals.You asked the Plan to pre-approveLumbar/Sacral Transforaminal Epidurals. You say that you would like reconsideration because this service is medically necessary to treat the member's pain.The Plan denied your request. The Plan says the request does notmeet LCD criteria for coverage.The Plan follows Medicare rules. Medicare rules say that no more than two transforaminal injections may be performed at a single setting.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 Lumbar/Sacral Transforaminal Epidurals. Our reviewer says that the request is for 3 levels of transforminal epidural steroid injections. Our physician reviewer found the LCD limits the number of epidural steroid injections to 2 per session.  Therefore, only 2 transforminal epidural steroid injections are considered 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 Lumbar/Sacral Transforaminal Epidurals have not been met.Therefore, we decided that the Plan does not have to pre-approveLumbar/Sacral Transforaminal Epidurals.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure, NSTEMI, cardiac catheterization and acute renal failure requiring hemodialysis. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee would 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) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral sacroiliac (SI) joint injections.You asked the Plan to pre-approvethese 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic pain involving the right thigh, right upper back, right buttock, abdomen, left buttock, right and left lower back and the left anterior neck after falling from a height. There is no evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. There is no evidence that the enrollee has participated in a four to six week aggressive physical therapy program, an activity modification program, or an active rehabilitation/therapeutic exercise program. There is no documentation of at least three positive exam findings of SI joint dysfunction on physical exam. The SI injections are therefore 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral sacroiliac (SI) joint injections
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePegfilgrastiminjection (J2505).You asked the Plan to pre-approvePegfilgrastim. You say that this service is medically necessary.The Plan denied your request. The Plan says the service is not considered medically necessary.The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Multiple attempts by the Plan to receive medical records were not successful.Therefore, we decided that the Plan does not have to pre-approvePegfilgrastim injection (J2505)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveproton beam therapy for the enrollee.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary forthe treatment of prostate cancer.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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a heated issue, with quite disparate opinions among experts in the field. In general, proton therapy is more expensive than photon therapy, which is the root of the disagreement of experts. Whether proton therapy for prostate cancer affords any advantage over IMRT is very controversial. Any potential benefit or detriment of proton therapy over standard IMRT is an investigational question (being pursued in randomized studies-i.e. for intermediate to low risk prostate cancer. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.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 therapy have not been met.Therefore, we decided that the Plandoes not haveto pre-approveproton beam therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient surgery allograft (Orthofix Trinity) (20931),
structural allograft (Orthofix Trinity) (20930), and bone marrow aspirate (20939).
You asked the Plan to pre-approve outpatient surgery allograft (Orthofix Trinity), structural allograft (Orthofix
Trinity), and bone marrow aspirate. You say that the services are medically necessary. The Plan denied your
request. The Plan says the service is not medically necessary or reasonable.
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 outpatient surgery allograft (Orthofix
Trinity), structural allograft (Orthofix Trinity), and bone marrow aspirate. Our reviewer says that the requested
services are not considered medically reasonable and necessary in this case. Our physician reviewer found
trinity allograft and bone marrow aspirate remain experimental for use in cervical spine 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 outpatient surgery allograft (Orthofix Trinity), structural allograft (Orthofix
Trinity), and bone marrow aspirate have not been met. Specifically, the service requested is considered
experimental and, therefore, cannot be considered medically necessary or reasonable. Therefore, we decided
that the Plan does not have to pre-approve outpatient surgery allograft (Orthofix Trinity) (20931), structural
allograft (Orthofix Trinity) (20930), and bone marrow aspirate (20939).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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.