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

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found regarding rehabilitation services, the beneficiary did not receive nor require skilled services and was dependent for care and mobility. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 SNF care, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of the lower extremity arteries.
You asked the Plan to pre-approve duplex scan. You say that you are appealing. The Plan denied your request.
The Plan says the denial of authorization for this service is correct.
The Plan follows Medicare rules. Medicare rules say that non-invasive vascular studies are only deemed
medically necessary when certain conditions are met.
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 duplex scan. Our reviewer says that you
do not meet the Medicare criteria for the requested duplex scan. Our physician reviewer found based on the
records submitted you have a history of lower extremity neuropathy but are not ambulating, do not have
documented claudication, and have a normal lower extremity examination including normal pulses. The Ankle-
Brachial Index (ABI) is not reported. In this circumstance of no documented signs or symptoms of lower
extremity arterial disease, the records do not support the medical necessity of the requested duplex scan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of duplex scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve a duplex scan of the lower extremity arteries.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106). You asked the Plan to pre-approve Retacrit. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided the documentation does not support that the Retacrit is medically reasonable and necessary or safe and effective for the enrollee. There is no report of myelodysplastic syndrome, chronic kidney disease or other Medicare-approved compendia accepted indication for Retacrit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder (73221).
You asked the Plan to pre-approve an MRI of the shoulder. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the shoulder. Our reviewer says that the service is not medically necessary. Our physician reviewer found in this case there, is no documentation of a face-to-face evaluation or physical examination being performed to evaluate the left shoulder pain. In addition, there is no documentation of an attempt or failure to respond to medical therapy or a trial of physical therapy. The review has determined that the requested MRI of the left shoulder is not medically reasonable or 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 an MRI of the shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the shoulder (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), attendant control (E2331), power seat elevation system (E2300), arm pad replacement (K0019 x2), electronic connection between wheelchair controller and two or more power seating system motors (E2311), super soft foam insert (K0108), cantilever recline armrest pair (K0108), and 8 way rocker (K0108).
You asked the Plan to pre-approve an expandable controller, harness for upgrade to expandable controller, attendant control, power seat elevation system, arm pad replacement, electronic connection between wheelchair controller and two or more power seating system motors, super soft foam insert, cantilever recline armrest pair, and 8 way rocker. You say that the requested items are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature and that wheelchair seat and back cushion codes are all-inclusive. 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 expandable controller, harness for upgrade to expandable controller, attendant control, power seat elevation system, arm pad replacement, electronic connection between wheelchair controller and two or more power seating system motors, super soft foam insert, cantilever recline armrest pair, and 8 way rocker. Our reviewer says that the items are not medically necessary. Our physician reviewer found none are necessary. The requested accessories are not necessary for functioning of a power mobility device. A standard device can address this enrollee's mobility and mobility related activity of daily living (MRADL) needs. As such, these requests are 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 an expandable controller, harness for upgrade to expandable controller, attendant control, power seat elevation system, arm pad replacement, electronic connection between wheelchair controller and two or more power seating system motors, super soft foam insert, cantilever recline armrest pair, and 8 way rocker have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), attendant control (E2331), power seat elevation system (E2300), arm pad replacement (K0019 x2), electronic connection between wheelchair controller and two or more power seating system motors (E2311), super soft foam insert (K0108), cantilever recline armrest pair (K0108), and 8 way rocker (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra (J3262).
You asked the Plan to pre-approve Actemra. You say that this is medically necessary. The Plan denied your
request. The Plan says this use of the drug is not supported.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Actemra. Our reviewer says that the
requested use of Actemra is not supported in this case. Our physician reviewer found subcutaneous use of
Actemra is indicated for the treatment of giant cell arteritis. Intravenous use of Actemra has been requested.
While intravenous use of Actemra is indicated for other conditions, there is no documentation to support why
intravenous administration is being requested to treat giant cell arteritis in this patient. As such, the request 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 Actemra have not been met. Therefore, we decided that the Plan does not have
to pre-approve Actemra (J3262).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the neck.
You asked the Plan to pre-approve MRI. You say that you are in severe pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct.
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 MRI. Our reviewer says that you do not meet the Medicare criteria for the requested MRI. Our physician reviewer found there is no documentation of prior evaluation or management of your symptoms. The history of your symptoms is incomplete and does not document duration of symptoms or prior treatments. There is no documentation of any red flag findings, such as acute or progressive muscular weakness or concern for malignancy or acute infection. There is no documentation of a trial of conservative care. Therefore, the requested MRI 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the neck.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), an electrical connection (E2311), a seat elevation system (E2300), and a gel footplate cover (K0108).
You asked the Plan to pre-approve an expandable controller, a harness, an electrical connection, a seat elevation system, and a gel footplate cover. You say that you urgently need these items. The Plan denied your request. The Plan says these items are not medically necessary.
The Plan follows Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 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 expandable controller, a harness, an electrical connection, a seat elevation system, and a gel footplate cover. Our reviewer says that the requested items do not meet criteria for coverage. Our physician reviewer found the documentation does not support that an expandable controller (E2377), a harness (E2313), and an electrical connection (E2311) are medically reasonable and necessary for the enrollee in this case for the noted functions. The records do not show the gel footplate cover serves a medical purpose and is medically necessary. The power seat elevation system is not covered under Medicare rules. 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 expandable controller, a harness, an electrical connection, a seat elevation system, and a gel footplate cover have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), an electrical connection (E2311), a seat elevation system (E2300), and a gel footplate cover (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says that the denial of authorization for IRF service 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 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does require an acute hospital stay with an interdisciplinary approach to rehabilitation care. The enrollee does require treatment by multiple therapies and an intensive rehabilitation therapy program. There is 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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-approve Procrit/Epogen for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the information provided by the doctor does not the Medicare guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the drug is supported
for an indication of anemia of anemia secondary to CKD when the enrollee will require a transfusion due to the
rate of hgb/hct decline, when the ESA is being used to reduce transfusion related risks, and when the TSAT
drawn within the last three months is less than 20%. However, it is unknown if the enrollee meets these
requirements. Per the documentation, the enrollee's last hgb/hct was 9.7/30.5. The review has determined that
the documentation does not support that the requested Procrit is medically reasonable or necessary for the
enrollee. The documentation does not support that the Procrit is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Procrit/Epogen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299). You asked the Plan to pre-approve Opdivo. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee does have a high mutational burden and would meet criteria for treatment with pembrolizumab but not nivolumab, Therefore, the service is 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 Opdivo have not been met.Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder arthroscopy surgery.
You asked the Plan to pre-approve shoulder surgery. You say that the enrollee tried physical therapy and would benefit from surgical intervention to address their condition. The Plan denied your request. The Plan says that the denial of authorization for this surgery is correct.
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 shoulder surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found current evidence-based medical literature supports surgical intervention in this case. There is clinical and imaging evidence of significant right shoulder pain, including rotator cuff, biceps tendon, and labrum pathology with underlying acromioclavicular (AC) joint osteoarthritis that would support synovectomy as indicated at the time of surgery, as well as extensive debridement. Surgical treatment of the biceps tendon is reasonably indicated based on the reported chronic tear and concomitant rotator cuff surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder surgery have been met. Therefore, we decided that the Plan has to pre-approve shoulder arthroscopy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test materials and equipment (G0249) provided on January 1, 2020.
You asked the Plan to pay for the test materials and equipment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services were billed for 6 billing days, which is earlier than required 25 billing days.
The Plan must follow Medicare rules. Medicare rules say that self-testing with the device should not occur more frequently than once a week. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test materials and equipment have not been met. Specifically, CPT code G0249 includes 4 tests per units. The NCD states that testing should not occur more frequently than once a week. These tests have been billed prior to 25 days from the last and have exceeded the frequency limitation. Therefore, we decided that the Plan does not have to pay for test materials and equipment (G0249) provided on January 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy. You say that you would like reconsideration because the member put physical therapy on hold and would like to resume treatment. The Plan denied your request. The Plan says if additional therapy is needed, additional documentation is necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional already authorized therapy can be used to safely transition the patient to and independent home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow deterioration. 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.