Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder rotator cuff repair surgery.
You asked the Plan to pre-approve the shoulder surgery. You say that you feel that this should be approved to help your symptoms. The Plan denied your request. The Plan says that the documentation does not support that this procedure is necessary at this time.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the shoulder surgery. Our reviewer says that the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee presents with a history of chronic right shoulder rotator cuff syndrome. He reports increased right lateral deltoid shoulder pain over the past 8 months with associated weakness and sleep disturbance. Functional limitations are noted in activities of daily living. Clinical exam findings have documented loss of range of motion, weakness and positive impingement signs consistent with imaging evidence of a focal full thickness rotator cuff tear with retraction. Reasonable and/or comprehensive long-term conservative treatment, including activity modification, NSAIDs, and home exercise program have been reported. A prior subacromial corticosteroid injection in October 2017 provided marked symptom relief. Under consideration is a request for right shoulder rotator cuff repair. Current evidence based medical literature would support surgical intervention at this time. Additional conservative treatment, including formal physical therapy, is not indicated in the setting of a full thickness retracted tear. Therefore, this request for right shoulder rotator cuff repair is 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 the shoulder surgery have been met. Therefore, we decided that the Plan has to pre-approve shoulder rotator cuff repair surgery.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee requires assistance with patient care and medical management. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 was involuntarily admitted to the hospital on December 12, 2019 with unspecified schizophrenia and attention deficit hyperactivity disorder (ADHD). Based on the submitted records, it is not expected that he will improve in a reasonable period of time, as he is not showing dangerousness to himself or others and has no auditory or visual hallucations or abnormal behaviors. It does not appear that active treatment is taking place. He is not showing suicidal or homicidal ideation and is compliant with treatment. The services are 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-approve inpatient psychiatric services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve a sacroiliac joint injection. 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 follows Medicare rules. Medicare rules say that sacroiliac joint injections are covered for certain indications. 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 sacroiliac joint injection. Our reviewer says that the documentation supports that the enrollee meets criteria for the requested injection services. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had steroid injections into the sacroiliac joint. One side is documented to provide 100% immediate pain relief and then
greater than 50% pain relief for 6 weeks. The documentation supports that the enrollee achieved greater than 50% pain relief for 6 weeks, which meets the LCD criteria. 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 a sacroiliac joint injection have been met. Therefore, we decided that the Plan has to pre-approve a sacroiliac joint injection.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRocklatan.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveRocklatan.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAmbien.You asked the Plan to pre-approveAmbien. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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 arenot among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAmbien.Benefits for Ambienmay be available under Medicare Part D.Contactthe Plan that administers Part Dbenefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveeustachian tube balloon dilation.You asked the Plan to pre-approvethese services. You say that the procedure will reduce further costs related to your care.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase 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 medically necessary. Our physician reviewer found the submitted records showthat you have chronic mucoid otitis media due to eustachian tube dysfunction (ETD). You have undergone appropriate medical management and also numerous procedures with pressure equalization tube placement. Your symptoms improved temporarily but then return when the tube extrudes or becomes clogged. The requested procedure is reasonable and medically necessary at this time to ensure that your condition does not worsen.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 been met.Therefore, we decided that the Plan has to pre-approveeustachian tube balloon dilation.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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea platelet rich plasma injection to the knee for "the beneficiary".You asked the Planto pre-approvethe injection. You say that this procedure will lubricate the joint to prevent further injuries.The Plandenied your request. The Plansaysthis is not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider services coded with CPT 0232T to be medically necessary. The requested injection is coded with CPT 0232T. Based on this information, we decided that Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea platelet rich plasma injection to the knee for "the beneficiary".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea segmented pneumatic compression device.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere has been no four week trial of a lesser device.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate this enrollee has unique characteristics that necessitate a segmented pump, and/or has proximal lymphedema. There is no documentation of failure to respond to a reasonable basic pump (trial period).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea segmented pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysyour condition must be of a level of complexity that requires an intensive and coordinated interdisciplinary approach including physician visits at least three times weekly.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvespine surgery.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthecode used is incorrect and cannot be approved.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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clear documentation of instability of the spine in the records. There are no flexion-extension views showing instability. Fusion is not medically needed. Distraction device is not needed also. It remains experimental.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvespine surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approvethe admission. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be met at a lower level of care, such home health at home with supervision or in an assisted living facility with home health services.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 the provided medicalrecords do not indicate a need for skilled nursing services. The provided medical records do not indicate a need for daily skilled services. The provided medical records do not indicate a need for inpatient services. Care in the home or an assisted livingfacility with home health services or in a long term care facility with intermittent therapy services appears to be appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
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 it is felt that LTACH care would be the best option for the enrollee's care.The Plan denied your request. The Plan says the current facility is able to meet the enrollee's needs.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs includeoxygen supplementation with nighttime BiPAP, surveillance laboratory studies, nutrition assessment, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, 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, thefile, 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve75 round-trip routine transportation trips for "the beneficiary".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 request exceeds the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year (12 round trip).We looked at your request, the records in the case file, and the rules. The requested services are 75 round trips. The Plan covers only 12 round trips. Therefore, we decided that the Plan does not have to pre-approve75 round-trip routine transportation trips for "the beneficiary".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided.You asked the Plan to pre-approvethese services. You say that you have a rare form of cancer and would like to be seen at this facility.The Plan denied your request. The Plan says the services are available from network providers.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 Plan does not have to pre-approvemedical services to be provided.
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 necesary. The Plan denied your request. The Plan says there are lower level of care facilities that have beds available.

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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation, surveillance laboratory studies, tube feedings, wound care, and therapies. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dicyclomine 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 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 dicyclomine 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.