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 IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF 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 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 patient has a past medical history of hypertension, gout and stage 4 chronic
kidney disease and is living at home with increasing weakness and increasing fall frequency. Their medical
problems are stable. The patient does 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. In addition, there
is not a reasonable expectation that this patient 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: 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 SNF care is medically necessary. 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 the beneficiary is an 81-year-old female who
is a long-term-care resident. She has a variety of medical conditions including diabetes, dementia and acute
respiratory failure. There are no identifiable skilled nursing service needs and no identifiable skilled therapy
service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis
and 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee was admitted for surgical repair for a hip fracture after a fall. The
enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not
support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be
met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac catheterization procedures (procedure codes
93459, 93460, and 93461).

You asked the Plan to pre-approve cardiac catheterizations. You say that you have spiking blood pressure
which medication does not help. The Plan denied your request. The Plan says the denial of authorization for
these services is correct, because you do not have an indication for which these catheterizations have clinical
value and effectiveness.

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 cardiac catheterizations. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you have been referred for left heart catheterization and coronary angiography, for
which the Plan approved the appropriate procedure code 93458. You have not had coronary bypass grafting so
the requested procedure codes 93459 and 93461 are not relevant or indicated. You have no history of right or
left heart failure or valvular heart disease, and your history, clinical exam, and Echocardiogram were not
reported to suggest left valvular or right valvular dysfunction, cardiac shunting, valvular disease, pulmonary
hypertension, or any other clinical indications for right heart catheterization. Therefore, procedure code 93460
is also not indicated for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of cardiac catheterizations have not been met. Therefore, we decided that the Plan
does not have to pre-approve cardiac catheterization procedures (procedure codes 93459, 93460, and 93461).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid.

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 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 Synthroid.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 33-year-old male who was admitted to the hospital due to confusion and difficulty breathing. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 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 the enrollee requires that are not available at the health care setting being offered by the health plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic mammogram.

You asked the Plan to waive the cost share for the mammogram. You say that you were never charged before for this type of exam. The Plan denied your request. The Plan says the determination was based on your plan.

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 $275 copay for each Medicare-covered diagnostic radiology.

The Plan contract shows that there is a $275 copay for each Medicare-covered diagnostic radiology services. However, you were only charged $165.53 for the services provided. The mammogram falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay 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 waive the cost share for the diagnostic mammogram.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will have a better outcome at the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in, and benefit from, the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. 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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis with neurogenic claudication. The Vertiflex spacer device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does 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 Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left sacroiliac (SI) joint fusion and the bone marrow
aspirate (27280, 20939).

You asked the Plan to pre-approve the left SI joint fusion and the bone marrow aspirate. You say that these
services are medically necessary. The Plan denied your request. The Plan says the effectiveness of the
requested services has not been demonstrated in the peer-reviewed literature.

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 left SI joint fusion and the bone
marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found This 70-year-old female is being treated for spinal
stenosis and degenerative joint disease.

SI Joint Fusion

Regarding the SI joint fusion, detailed documentation is not evident regarding SI pathology on the recent CT
scan or lumbar x-ray. There are multiple other plausible pain generators evident, including at lumbosacral spine
levels. Documentation that these have been investigated and fully ruled-out is not evident. Furthermore,
detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less
invasive conservative care measures specific for the SI joint.

Bone Marrow Aspirate

There is no specific indication provided to support the request for bone marrow aspirate for the approved
surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical
necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this
enrollee's medical condition.

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 left SI joint fusion and the bone marrow aspirate have not been met.
Therefore, we decided that the Plan does not have to pre-approve the left sacroiliac (SI) joint fusion and the
bone marrow aspirate (27280, 20939).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Remicade (J1745).

You asked the Plan to pre-approve Remicade. You say that the enrollee has been stable on the requested therapy. The Plan denied your request. The Plan says that Remicade is not considered medically necessary for the treatment of hidradenitis suppurativa.

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 Remicade. Our reviewer says that Remicade (J1745) is medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Remicade (J1745) is not FDA-approved for the enrollee's diagnosis. Our reviewer also found that the use of Remicade (J1745) is supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have been met. Therefore, we decided that the Plan has to pre-approve Remicade (J1745).

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-approve a prosthetic limb with socket and accessories.

You asked the Plan to pre-approve a prosthetic limb with socket and accessories. You say that you need a new
prosthetic. The Plan denied your request. The Plan says you have not had a change in your condition or
irreparable wear of the device.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. In addition, a replacement of a prosthesis will be covered when there is a change in
the physiological condition of the beneficiary.

The file shows that you have a prosthetic limb. This prosthetic limb serves the same purpose as a prosthetic
limb with socket and accessories. In order for a new prosthetic limb to be covered, you provider would need to
note a change in your physiological condition. Your provider has not noted a change in your medical condition.
Therefore, we decided that the Plan does not have to pre-approve a prosthetic limb with socket and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.

You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this procedure due
to his worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because CardioMEMS is experimental/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 CardioMEMS. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the CardioMEMS system is indicated for wirelessly measuring and monitoring pulmonary
artery pressure and heart rate in Class III heart failure patients who have been hospitalized for heart failure in
the previous year. The available documentation does not support that the enrollee has Class III heart failure or
that his hospitalization 1 year ago was for heart failure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 72-year-old male with multiple medical problems who was admitted to an acute care hospital on April 6, 2021, with problems due to pain on the left leg and a left diabetic foot wound. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 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 the enrollee requires that are not available at the health care setting being offered by the health plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT
code 22869, and 22870), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are 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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.
Open laminectomy is the gold standard.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869, and 22870), for the
enrollee.