Persius/hicric huggingface dataset:
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 services are 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 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly
moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive,
longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted
period. An IRF intensity is not warranted.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoroscopic guidance for insertion of needle and aspiration of a large joint or joint capsule..You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says there was no additional documentation submitted to support the medical necessity of this procedure.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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports that you have ongoing left hip and groin pain. You had a joint aspiration that noted not bacterial growth and a normal peripheral complete blood count. You have received steroid and analgesic injections of the hip with little pain improvement. You were noted to have an elevated sedimentation rate level and was referred a rheumatologist. A repeat aspiration was recommended. The documentation does not outline the rationale for a repeat aspiration. There is not any evidence such as fever or elevated peripheral white blood cell count to suggest infection, and a specialty appointment with a rheumatologist was nt completed. Without the supporting documentation, a repeat aspiration is not determined 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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve fluoroscopic guidance for insertion of needle and aspiration of a large joint or joint capsule.
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 services are 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 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 complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple
therapies such as physical and occupational therapy but the documentation does not support that your
endurance level can tolerate an intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Sincerely,
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH services.The Plan denied your request. The Plan says LTACH services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to an acute care hospital due to respiratory failure and endocarditis. She was treated with mechanical ventilation, IV antibiotics, hemodialysis, a chest tube for pneumothorax, tube feedings, and wound treatment. Current clinical status of the enrollee is fair, improving and stable. The enrollee's current needs are basic wound care, chest tube care, hemodialysis, IV antibiotics, tube feeds, and Foley management, all of which could be managed at a lower level of care. The enrollee appears to be stable enough for transfer to a lower level of care. There are also no evidence of a need for care in an LTACH which is not available at the current acute care 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3320) and the addition post and core to a crown (D2954).You asked the Plan to pre-approve a root canal and the addition post and core to a crown. You say that you need these services because you are in pain.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) and the addition post and core to a crown (D2954).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the requested procedure will be performed in the setting of a Medicare-approved clinical trial.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental, and more research is needed to show safety and efficacy. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility 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 the enrollee is no longer being provided active treatment associated with a need for
acute inpatient level of care.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a
review of the records provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental
health facility beyond the date in question of July 7, 2020. The enrollee could be treated in a lesser restrictive
setting, as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions,
and was not showing any catatonia or aggression, being cooperative and compliant. There were no acute threats
to safety.
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 an inpatient mental health facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #5 for the enrollee.
You asked the Plan to pre-approve the crown. You say that this is needed to restore proper anatomy and function. The Plan denied your request. The Plan says there is no evidence of a pathologic destruction of the teeth warranting a crown.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in the present case the supplied panoramic x-ray shows tooth #5 with either a small or no existing restoration that can be seen on the panoramic view. There are no damaged cusps present. There is no indication of substantial structural loss that would require a full coverage restoration to strengthen the tooth. Given the lack of structural damage to tooth #5 there is no medical necessity for a crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #5 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolia injection 60 MG/ML syringe (J0897).
You asked the Plan to pre-approve the Prolia injection. You say that the denial reason is inaccurate and the enrollee has not had the injection since October of last year. The enrollee was due for the injection but due to COVID-19 the enrollee never received the injection in May. The Plan denied your request. The Plan says the maximum dispensing limit for this drug is 1 syringe per 180 days. A review of pharmacy claims was performed and a recent paid claim was found for 1 syringe on 5/28/2020.
The Plan must follow Medicare rules. Medicare has specific dosing requirements for this drug. This drug is available (covered) when dispensed as 1 syringe every 6 months. A recently attempted refill caused a computerized error code, stopping coverage. This is because the calculated amount appeared to be: either above the covered amount, or had an unusual dispensing interval. The Plan has approved coverage of the dosing amount supported and requested by your physician. Your physician has indicated you may be dosing beyond the suggested guidelines. Anything over the suggested guidelines will not be approved by the plan. Medicare coverage criteria for the additional refills requested are not met. Therefore, the Plan is not required to provide coverage for doses beyond what was prescribed. Therefore, we decided that the Plan does not have to pre-approve the Prolia injection 60 MG/ML syringe (J0897).
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 requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested IRF admission.
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 enrollee does not meet criteria for the requested IRF admission. Our physician reviewer found based on the documentation provided, 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'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: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 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 the enrollee does not require daily skilled nursing or daily skilled rehab care.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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 the services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued admission 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-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to get stronger. The Plan denied your
request. The Plan says you do not meet Medicare criteria for admission to acute inpatient rehabilitation. The
Plan says that you can receive the care 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 based on the medical records provided, the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You require physical therapy and occupational therapy services but based on the medical
records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical
records provided, there is no documentation that you require the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more
appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says that a second injection
is more than the maximum allowed dose for the enrollee's indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Zilretta. Our physician reviewer found
that the enrollee has bilateral knee pain due to osteoarthritis. The enrollee is not a candidate for a total knee
replacement. The enrollee has received a left knee Zilretta injection and has had bilateral knee injections with
Synvisc. This request is for a repeat Zilretta injection of the left knee. The labelling of the drug has changed.
Based on the Label, it does not preclude use of the drug more than one time. Where the labeling once stated
that Zilretta is not intended for repeat administration, the labeling now states that the safety and efficacy of
repeat administration has not been established. There is current medical literature supporting the safety and
efficacy of a second injection of extended-relief triamcinolone acetonide. A second injection of the drug
resulted in a similar magnitude and duration of clinical benefit as a first injection, and was well-tolerated. The
documentation supports that Zilretta is medically reasonable and necessary, and 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve
Zilretta.
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. The Plan denied your request. The Plan says there are no complex
medical conditions that require physician monitoring 3 times a week.
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 the enrollee presented to the acute hospital with palpitations and dyspnea on exertion. He was treated in the
hospital with a Cardizem drip for atrial fibrillation with rapid ventricular response. He was also treated for
encephalopathy, pneumonia and hematuria. His atrial fibrillation was treated with amiodarone, Eliquis and
Lopressor. His antibiotics (Rocephin) have been transitioned to Augmentin and he will follow-up as an
outpatient with urology for a cystoscopy. He is weak and deconditioned and is working with physical and
occupational therapy. He is walking 50 feet with minimum assistance with a rolling walker and is minimum to
moderate assist for transfers and he is supervision/stand-by assist for activities of daily living. He is medically
stable. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require
physical therapy and occupational therapy services, but he does not require an intensive inpatient rehabilitation
therapy program. There is concern that he will not be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an inpatient rehabilitation facility.
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.