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

We decided that the Plan does not have to pre-approve a lumbar epidural injection.
You asked the Plan to pre-approve the requested services. You say that the enrollee has chronic low back pain
with bilateral radiculopathy. The Plan denied your request. The Plan says the service is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered under
certain medical 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 the requested services. Our physician
reviewer found that the enrollee has chronic low back pain with radiculopathy secondary to severe spinal canal
stenosis and bilateral foraminal stenosis at L4/L5 and L5/S1. The enrollee had a left epidural steroidal injection
with minimal relief. The enrollee has failed physical therapy and medications. A lumbar decompression was
planned but postponed due to COVID and complications. A lumbar MRI reported multilevel lumbar
spondylosis with L4/L5 severe canal narrowing and mild right foraminal narrowing. In this case, there is no
actual physical exam or actual MRI report sent for this review. The notes did not show that pain or function
improved after the last injection. The first injection did not help the enrollee's pain. The enrollee does not meet
the coverage criteria for the requested injection. Therefore, the requested injection is not 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a lumbar epidural injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extraction services.
You asked the Plan to pre-approve the dental extraction services. You say that you have been sickly for years
and that the removal of the rotten teeth will greatly improve your quality of life. You say that you are always
on pain medicine due to your constant pain, and that you are concerned about liver and kidney damage. The
Plan denied your request. The Plan says the requested services exceed the benefit allowance for dental
extractions.
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 benefit for dental extractions is
limited to 3 per calendar year. The records show that the Plan approved coverage for the surgical removal
(extraction) of tooth #2, #4, and #6. This exhausted the benefit for dental extraction services in the 2020
calendar year. Therefore, we decided that the Plan does not have to pre-approve dental extraction services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L2/L3 kyphoplasty for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the pain criteria has not been met.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a pain score, showing severe back pain, The enrollee has adenocarcinoma at L2 and L3. The criteria for kyphoplasty is not 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve L2/L3 kyphoplasty for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lisinopril 40mg tablets.
You asked the Plan to pre-approve the lisinopril tablets. You say that this medication is necessary as it has led
to good blood pressure control. The Plan denied your request. The Plan says this is an oral drug that is only
covered under Medicare Part D.
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 lisinopril 40mg tablets.
Benefits for the lisinopril tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat feature for your wheelchair.
You asked the Plan to pre-approve a power seat feature. The Plan denied your request. The Plan says this is not
a covered service.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is noncovered
because it is not primarily medical in nature.
We looked at the file and Medicare rules. The requested power seat elevation feature (E2300) is not considered
to be primarily medical in nature, and therefore is not covered. Therefore, we decided that the Plan does not
have to pre-approve a power seat feature for your wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-sharing for levalbuterol nebulizer solution.
You asked the Plan to reduce the cost-sharing for Part B drug. You say that you are on a fixed income and need
the Plan's assistance to afford this drug. The Plan denied your request. The Plan says the denial of authorization
for a cost-sharing reduction is correct, because this drug is covered by Medicare Part B and Part B drugs are not
eligible for cost-sharing reduction.
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 20%
coinsurance for the Medicare Part B drug levalbuterol.
You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls within the Medicare Part B
Prescription Drugs 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 reduce the cost-sharing for levalbuterol
nebulizer solution.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail the Rituximab biosimilars Truxima and Ruxience first.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 Rituxan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation provided, the enrolleeis noted to have fibrillary glomerulonephritis, for which rituximab use has been requested. There is no evidence that the enrollee has non-Hodgkin's lymphoma, chronic lymphocytic leukemia or rheumatoid arthritis. There is no evidence that the enrollee has used steroids or other immuno suppresants. Limited studies have not shown significant benefit from the use of rituximab. Therefore, the requested drug is not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met.Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient skilled
nursing facility admission.
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 care. Our reviewer says that an
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you
do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do 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 an inpatient skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is
medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for coverage of
an inpatient skilled nursing facility admission.
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 care. Our reviewer says that an
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you
do not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter,
you do 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 an inpatient skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851).
You asked the Plan to pre-approve a knee orthosis (L1851). You say that the requested knee orthosis (L1851) is
medically necessary. The Plan denied your request. The Plan says the enrollee does not have a covered
indication for the requested knee orthosis (L1851).
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 knee orthosis (L1851). Our reviewer
says that the enrollee does not have a covered indication for the requested knee orthosis (L1851). Our physician
reviewer found based on the documentation provided, the enrollee is noted to have knee pain. There is no
evidence of a recent injury or surgery. There is no evidence of knee instability. Therefore, the requested knee
brace is not shown to be medically necessary or reasonable.
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 knee orthosis (L1851) have not been met. Therefore, we decided that the Plan
does not have to pre-approve a knee orthosis (L1851).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met with part-time skilled services in long term care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found no skilled nursing needs are identified.
There are no noted daily skilled complex nursing needs. While the enrollee may benefit from continuing PT
and OT, the records do not support the need for daily therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs the device to
communicate. The Plan denied your request. The Plan says the necessary services may be obtained in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 documentation shows that a speech generating device was requested. 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 at
issue in this appeal. We found no exception that would require the Plan to pre-approve these services.
Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out
of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's care can be given more safely at a skilled nursing facility. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, HHS, LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4mg Ondansetron Tablets.
You asked the Plan to pre-approve the Ondansetron. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the member does not meet criteria for coverage
of this drug under Medicare Part B.
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 4mg Ondansetron Tablets.
Benefits for the Ondansetron 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 acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care 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 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 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 already ambulating household distances. 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 8, 2020.You asked the Plan to pre-approveSNF care. You say that you are being discharged from the SNF too soon.The Plan denied your request. The Plan says that the denial of authorization for continued SNF care after July 8, 2020 is correct.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 8, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after July 8, 2020.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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to build strength for a safe return to everyday living. The Plan denied your request. The Plan says there is no need for supervision by an inpatient rehab physician 3 times a week, or an intensive rehab therapy program. 
 
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 physician reviewer found that you have a past medical history of a subdural hematoma. You were admitted to the hospital with syncope, recurrent falls, and confusion. You were found to have severe bradycardia, and a pacemaker was placed. Acute renal failure has improved. You are medically stable at this time. There is no evidence of complex medical issues that require acute rehab nursing care, and monitoring by an inpatient rehabilitation physician three times per week. While you may benefit from continuing speech, physical, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 dentures.
You asked the Plan to pre-approve the dentures. You say that you are constantly in pain and on medication.
You say that you are worried about liver and kidney damage. The Plan denied your request. The Plan says the
requested dentures are a non-covered benefit.
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, dentures are not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pre-approve dentures.