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

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysin-network options have not been exhausted.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAricept tab 10mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medicallynecessary for senile degeneration of brain.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.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 Plandoes not haveto pre-approveAricept tab 10mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic evaluation and management services (CPT 99204).
You asked the Plan to pre-approve the chiropractic evaluation and management services. The Plan denied your request. The Plan says the only covered chiropractic services are manual manipulation of the spine to correct subluxation. The plan says that office visits and evaluations performed in a chiropractor's office are not a Medicare-covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the request is for evaluation and management services from a chiropractor. This means that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a chiropractic evaluation and management services (CPT 99204).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea limited/localized follow up computed tomography (CT) scan.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 CT scan is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewerfound the enrollee has a diagnosis of benign prostatic hypertrophy causing lower urinary tract symptoms. He has declined procedures. The records do not support that the requested limited/follow up CT is reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea limited/localized follow up computed tomography (CT) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested LTACH care is medically necessary.The Plan denied your request. The Plan says the enrollee can receive all necessary care in the current facility.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 patient is currently undergoing treatment at an ACH, having been admitted with 3rd degree heart block. The enrollee subsequently developed respiratory failure and pneumonia, for which she was intubated/ventilated. The enrollee received a tracheotomy and appears tohave since been weaned from the ventilator to a tracheotomy collar. 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 LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe five additional dental extractions, alveoloplasty, and upper and lower dentures.You asked the Plan to pre-approvethe extractions, alveoloplasty, and dentures. You say that you have tooth decay and this has kept your blood sugar unstable. You are not able to eat properly and keep getting sinus infections.The Plan denied your request. The Plan says you were approved for one extraction as this is covered by the Plan. Additional extractions and the other requested services are not covered by your Plan.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-approvethe five additional dental extractions, alveoloplasty, and upper and lower dentures.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveamagnetic resonance imaging (MRI) of the right ankle (73721).You asked the Plan to pre-approvean MRI of the right ankle. You say that the requested MRI is needed to determine the cause of your pain.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the right ankle. Our reviewer says that the service is not medically necessary. Our physician reviewer found submitted documentation does not include subjective complaints of ankle pain, physical examination abnormalities of the ankle, plain film imaging of the knee, or differential diagnosis related to ankle conditions. Without the support of the documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the right ankle have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the right ankle (73721).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox injections to be provided by an out of network provider.You asked the Plan to pre-approvethe out-of-network services. The Plan denied your request. The Plan says you can get this shot from 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 pre-approved care.You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approveBotox injections to be provided by an out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc for "the beneficiary".You asked the Plan to pre-approveSynvisc. The Plan denied your request. The Plan says the enrollee has not had previous treatment, a contraindication to, or intolerance with Orthovisc and Monovisc.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 Synvisc. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approveSynvisc for "the beneficiary".
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.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 admission is not medically necessary.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 these services. Our reviewer says that dailyskilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on January 5, 2020. You received oral medications and insulin and had stable vital signs. You received physical therapy in the hospital and need assistance with bed mobility and transfers. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF intensive therapy is needed to allow for recovery.The Plan denied your request. The Plan says the criteria for the requested level of care have 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 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 enrollee is a female who was admitted to the hospital on 12/31/2019 with diverticulitis with associated abscess. She had a JP drain placed. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is consistently ambulating more than 100 feet. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee would be better served by a more intensive therapy program.The Plan denied your request. The Plan says daily therapy in the SNF will be sufficient.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 enrollee underwent a total hip replacement on 12/117/2019 and was discharged to SNF the next day. She was then readmitted on 1/3/2020 due to a dislocation of the hip prosthesis for which closed reduction was done. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Filgrastim.
You asked the Plan to pre-approve Filgrastim. You say that the drug is medically necessary. The Plan denied
your request. The Plan says Filgrastim is 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 Filgrastim. Our reviewer says that
Coverage criteria has not been met at this time. Our physician reviewer found the enrollee had one episode of
severe neutropenia. He does not meet the definition of chronic severe neutropenia to cover Filgrastim.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Filgrastim.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Bioness L300 Go Foot Drop System and Bioness L300 Go Thigh Plus System.You asked the Plan to pre-approvea Bioness L300 Go Foot Drop System (E0770) and BionessL300 Go Thigh Plus System (E1399). You say that the Bioness would prevent disuse atrophy and increase joint range of motion.The Plan denied your request. The Plan says the enrollee does not meet criteria.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 a Bioness L300 Go FootDrop System (E0770)and Bioness L300 Go Thigh Plus System (E1399). Our physician reviewer found the Bioness L300 Go FootDrop System (E0770) and Bioness L300 Go Thigh Plus System (E1399) is not medically necessary per National Coverage Determination (NCD) for Neuromuscular Electrical Stimulation (NMES) (160.12). Coverage for the use of NMES/FES is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. 
The medical records indicate that the enrollee's hemiplegia, footdrop and weakness are a result of a stroke at age 19 rather than a spinal cord injury therefore thecriteria for the Bioness System has not been met. 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 Bioness L300 Go FootDrop System (E0770)and Bioness L300 Go Thigh Plus System (E1399) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Bioness L300 Go Foot Drop System and Bioness L300 Go Thigh Plus System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisone for the enrollee.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone for the enrollee.
Benefits for these services 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Injectafer IV iron infusions.
You asked the Plan to pre-approve the Injectfer infusion. You say that the enrollee needs this IV iron in order to be able to start chemotherapy. The Plan denied your request. The Plan says that this cannot be approved without a trial of oral iron.
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 the Injectfer infusion. Our reviewer says that the requested IV iron supplementation is considered reasonable and necessary in this case. Our physician reviewer found this patient has significant iron deficiency anemia and is to start chemotherapy. She requires intravenous iron on several levels. She is elderly and the elderly are known to have poor systemic absorption of oral iron, she has significant anemia, and she requires rapid repletion as she is starting chemotherapy which will add to her anemia. Intravenous iron is reasonable and 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 Injectfer infusion have not been met. Therefore, we decided that the Plan has to pre-approve Injectafer IV iron infusions.
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 pre-approvecompression stockings identified with code A6451.You asked the Plan to pre-approvethe compression stockings. You say that you have varicose veins and leg swelling.The Plan denied your request. The Plan says compression stockings identified with code A6451 are not covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6451 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6451.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveLivalo 2mg tablets.You asked the Planto pre-approvethe Livalo tablets. You say that this medication is necessary and should be approved.The Plandenied your request. The Plansaysthis oral drug is not covered by 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 Plandoes not haveto pre-approveLivalo 2mg tablets.Benefits forthe Livalo tabletsmay be available under Medicare Part D.Contactthe 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 continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that your needs can be met at a lower level of care such in the home or an outpatient facility with physical and occupational therapy.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.