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

We decided that the Plan does not have to pre-approve a CT scan of the neck (70491) and a CT scan of the thorax (71260) for the enrollee.
You asked the Plan to pre-approve a CT scan of the neck (70491) and a CT scan of the thorax (71260). You say that the requested CT scan of the neck and thorax are medically necessary. The Plan denied your request. The Plan says the requested CT scan of the neck and thorax are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the neck (70491) and a CT scan of the thorax (71260). Our reviewer says that the requested CT scan of the neck and thorax are not medically necessary. Our physician reviewer found the enrollee is with malignancy oropharynx. The enrollee completed treatment in 2017. The enrollee's last scans were from July 2019. Per NCCN guidelines, a CT scan of the neck within 6 months of treatment is recommended. A CT scan of the chest should be clinically indicated in the records as medically necessary. Based on the documentation provided, there is no clinical indication and surveillance CT scans are not indicated routinely. 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 CT scan of the neck (70491) and a CT scan of the thorax (71260) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the neck (70491) and a CT scan of the thorax (71260) 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 for the enrollee.You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not have any conditions or treatments requiring an LTACH.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) having been admitted with shortness of breath. The enrollee was initially placed on BiPAP and subsequently was intubated/ventilated. The enrollee has since received a tracheotomy and has been liberated from the ventilator. The enrollee continues to aspirate, necessitating ongoing tube feeds and airway protection. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH 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 for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the breast.You asked the Plan to pre-approve the MRI. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no evidence of a high risk for breast cancer.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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found you have no documented increased lifetime risk of breast cancer, you do have clinical symptoms which are worrisome for breast cancer, particularly the crusty nipple discharge. The breast pain itself does not necessarily provide an indication for MRI but in conjunction with the discharge at age 79 and a negative peri areolar biopsy MRI is a reasonable and necessary test in order to evaluate for occult cancer.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 MRI have been met.Therefore, we decided that the Plan has to pre-approve MRI of the breast.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 toreview. 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 Plan does not have to pay forthe nursing facility care provided on October 11, 2019 by an out of networkprovider.You asked the Plan to pay fornursing facility care. You say that you are the only providers in the facility.The Plan denied your request. The Plan says these services were not authorized.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 pay for 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe nursing facility care provided on October 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.You asked the Plan to pre-approv ethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have stage IIIC lung cancer. The records show that you had low levels of neutrophil white blood cells (neutropenia) during a hospital admission on October 9, 2019. There is no documentation of fever associated with neutropenia. Neulasta is indicated for prevention against neutropenic fever if there is at least an intermediate risk of this fever. The records do not show that you are at high or intermediate risk; therefore, Neulasta is not considered safe and effective or reasonable and medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.You asked the Plan to pre-approve IRF care. You say that the enrollee has a history of falls, and needs to regain maximum function.The Plan denied your request. The Plan says the enrollee does not have a complex medical condition require close physician supervision oran intensive 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 in this case, the enrollee is at moderate to minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee is hemodynamically stable. There remain some ongoing balance deficits though, no fever or signs of toxicity are noted. 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.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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that you are not strong enough to take care of yourself after heart surgery.The Plan denied your request. The Plan says your needs are considered custodial.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby assist to minimum assist level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy on a daily basis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies haven't proven that the device is helpful for treatment of this health
problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is considered experimental, and more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an interspinous and/or interlaminar device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forOrthotic Devices provided April 16, 2019.You asked the Plan to waive the coinsurance forthe orthotic devices. You say that the coinsurance should be waived.The Plan denied your request. The Plan says the correct coinsurance was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Orthotics and Prosthetic devices. You have been asked to pay a 20% coinsurance for the orthotic devices. The orthotic devices fall within the Orthotics and Prosthetic devices benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forOrthotic Devices provided April 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). You asked the Plan to pre-approve the Gelsyn-3. You say that the member has tried other medication for knee pain without a positive result. The Plan denied your request. The Plan says the information submitted does not meet the plan's medical necessity guidelines for coverage.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 the Gelsyn-3. Our reviewer says that the provided medical records do not indicate that the member has tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the medical records do not indicate that the Plan's required drugs 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 the Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from care in the SNF setting.The Plan denied your request. The Plan says the enrollee does not need daily skilled service to maintain her condition.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 94 year old female who was admitted on 12/19/2019 with a GI bleed. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet, tolerating orals and tending to ADLs with minimal supervision. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point appear to be custodial and, as a practical matter, can be provided 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plandoes not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says an inpatient level of care is not needed at this time.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 therelevant 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 is not medically ready to consider this admission. The enrollee needs PT and OT, but would not be able to participate in the intensity of an IRF admission. Her therapy needs can be met at an SNF setting or home with HHS and PT and OT.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) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs system for the enrollee.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service has not been proven safe and effective in improving overall mortality in the outpatient study.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 requested services. Our physician reviewer found that the enrollee has a history of hypertension, chronic kidney disease, macroglobulinemia and congestive heart failure with preserved ejection fraction, requiring hospitalization.  Therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMs device is uncertain at this time according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met as the device should still be considered experimental or investigational.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 CardioMEMs system for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve occipital nerve blocks, and trigger point injections for the enrollee.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the requested services are experimental and investigational for the diagnosis of migraine and occipital neuralgia.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 requested services. Our physician reviewer found that the enrollee has chronic headaches, a seizure disorder and occipital neuralgia. Nerve blocks and trigger point injections are well established therapy with practice guidelines supporting their use. The request is medically necessary and reasonable.We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve occipital nerve blocks, and trigger point injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical injections. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says conservative therapies have not been tried and failed. The Plan follows Medicare rules. Medicare rules say that back 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 neck pain. His MRI shows multi-level disc disease as well as foraminal narrowing. The enrollee has not had recent physical therapy, home exercise, or other physical medicine therapies. He has not had a trial of conservative therapy,and facet injections are not a substitute for epidural steroid injections. Therefore, the requested procedures are 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical injections.