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

We decided that the Plan does not have to pre-approve Eylea 2 mg/0.5 ml.
You asked the Plan to pre-approve Eylea. You say that the provider's office does not supply Avastin. You say
that the provider feels it is medically necessary to receive this medication. You also say that this is a medically
necessary diagnosis for the requested drug. The Plan denied your request. The Plan says there is no
documentation of experiencing therapeutic failure or intolerance after a trial with a plan preferred medication,
Avastin for ophthalmic use. The Plan also says that coverage criteria has not been met.
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 Eylea. Our reviewer says that Eylea is
not medically necessary. Our physician reviewer found the Plan requires a trial of drug Avastin before they will
approve the requested drug. The reviewer found that the enrollee has not tried and failed the required drug. The
reviewer found that there is no documentation provided indicating that the Plan's required drug would likely be
less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea 2 mg/0.5 ml.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 were admitted for surgical treatment of a hip fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010 x2).
You asked the Plan to pre-approve implants. You say that you feel the services are medically necessary. The Plan denied your request. The Plan says the services at issue are not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve implants (D6010 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a joystick (K0108), joystick mount (K0108), and power seat elevation system (E2300).
You asked the Plan to pre-approve a joystick, joystick mount, and power seat elevation system. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered as requested.
The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. A power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. The requested joystick and joystick mount are included in the expandable controller and cannot be separately approved. The power seat elevation system is non-covered. Based on this information, we decided that Medicare rules for coverage of a joystick, joystick mount, and power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a joystick (K0108), joystick mount (K0108), and power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that medical conditions put the enrollee at risk for falling in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
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 scan. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has a history of intermittent headaches and difficulty with neck rotation recently. X-ray of the cervical spine revealed changes consistent with osteoarthritis. Given that this enrollee has alarming signs such as limited neck rotation and flexion along with weakness in arm, it would be medically appropriate to rule out nerve impingement at this time with an MRI of the neck. Therefore, the enrollee meets 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 an MRI scan have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan.
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 spoke protectors (K0065), an under-seat pouch and carrier (A9270), and a hand-rim upgrade (K0108).

You asked the Plan to pre-approve spoke protectors, an under-seat pouch and carrier, and a hand-rim upgrade. You say that you need these items. The Plan denied your request. The Plan says these items do not serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The items at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve spoke protectors (K0065), an under-seat pouch and carrier (A9270), and a hand-rim upgrade (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee does not meet all requirements for acute inpatient rehab and the enrollee's needed care can be safely given in a lower level of care such as a skilled or subacute nursing care facility or with outpatient services.
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 that 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 hemarthrosis of the right knee. The enrollee's medical problems are stable. 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 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 this 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingival irrigations (D4921), periodontal procedure
(D4999), and drugs or medicaments dispensed in the office for home use (D9630).
You asked the Plan to pre-approve the gingival irrigation, periodontal procedure, and drugs or medicaments.
You say that you believe these services are necessary and would like them to be approved for coverage. The
Plan denied your request. The Plan says these services are not covered under your benefit package.
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 a
gingival irrigations (D4921), periodontal procedure (D4999), and drugs or medicaments dispensed in the office
for home use (D9630).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 have a past medical history of Parkinson's disease and are living at home with increasing weakness and debility. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says intensity-modulated radiation therapy (IMRT) would be approved if requested.
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. There are also physical uncertainties about proton depth dose delivery which may make the actual radiation deposition in tissue less conformal than it may appear based upon the treatment plan. For this case, it is not clear if the patient is thought to have N1 (Stage IV) disease and/or whether or not the pelvic nodal regions are to be treated. The "representative" case shown in the letter of appeal does not depict pelvic nodal radiation. To date, there is 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 Plan does not have to pre-approve proton beam radiotherapy for the enrollee.
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 the enrollee requires LTACH services for recovery and healing. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for LTACH services.

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 there is no documentation provided necessitating admission to a LTACH. 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 she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate level of care at hospital discharge. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 receiving appropriate care at the present acute care hospital. There are no services at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed (E0303).
You asked the Plan to pre-approve the hospital bed. You say that you wish to appeal because you just had shoulder surgery and the bed you were given is too small for you due to your weight and size. The Plan denied your request. The Plan says the request does not meet the criteria as the enrollee only weighs 280 pounds and the request received does not have a medical order and/or a certification of medical necessity that justifies the requested service.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. The rules say that hospital beds are covered only with a physician's prescription and sufficient documentation in the patient's medical records to establish medical necessity. In this case, there is no medical order and/or a certificate of medical necessity in the records. The enrollee also does not meet the weight requirement for a
heavy duty, extra wide hospital bed. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the provider is not participating.
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 care that cannot be provided by network providers. 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 Plan does not have to pre-approve a referral to an out-of-network cardiologist.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by a Licensed Alcohol and Drug
Counselor (LADC).
You asked the Plan to pre-approve services with an LADC. You say that it is necessary for the enrollee to
continue treatment with the LADC. The Plan denied your request. The Plan says a Licensed Alcohol and Drug
Counselor has a designation not credentialed or covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that that Original Medicare does not allow all
professionals to directly submit charges for the services that they provide.
We looked at the file and Medicare rules. This provider type is not eligible in the Medicare program. Based on
this information, we decided that Medicare rules for coverage of services with an LADC have not been met.
Therefore, we decided that the Plan does not have to pre-approve services to be provided by a Licensed
Alcohol and Drug Counselor (LADC).