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 you have already tried a skilled nursing facility and you ended up in the hospital for a month the last time you were admitted to one. The Plan denied your request. The Plan says the clinical criteria for admission to an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery, right eye.
You asked the Plan to pre-approve Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation (66984). You say that the enrollee has difficulty driving with glare at night. The Plan denied your request. The Plan says the enrollee does not have a best corrected visual acuity of 20/50 or worse, nor has a two line decrease in visual acuity with glare testing.
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 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation (66984). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the enrollee reported blur and glare, her vision was documented to be 20/25 in the right eye with glasses, and 20/30+ with glare testing. The documentation does not support that all other coverage criteria have been met, and there is insufficient documentation of medical necessity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation (66984) have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract surgery, right eye.
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 this enrollee requires prolonged physical 
therapy and acute care, and admission to an LTACH is medically necessary. The Plan denied your request. The 
Plan says the enrollee is currently receiving appropriate care in the current acute care hospital, and a transfer is 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that is not available at the acute care hospital where they are currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: 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 these services are medically necessary. The Plan denied your request. The Plan says the records show that this enrollee would benefit from continued physical and occupational therapy, but the enrollee's rehabilitation needs do not require an intensive team for them to meet their functional goals. The necessary services can be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that 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. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not 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. Medically necessary services can be provided in a different 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic medial branch block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says only one set of injections can be requested at a time, because the percentage of pain relief from the first set of injections must be provided showing receipt of 80% pain relief.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has radiculopathy as a diagnosis. Therefore, she does not meet the criteria for this request. 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a second diagnostic medial branch block
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda with Ondansetron.
You asked the Plan to pre-approve Keytruda. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested drug is not being prescribed for a medically-accepted indication
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our reviewer says that the request is not medically necessary. Our physician reviewer found the enrollee is a 72-year-old who has been diagnosed with descending and rectal cancer. They have received 12 cycles of chemotherapy. In this case, the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda with Ondansetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Up Walker heavy duty walker (E0147).
You asked the Plan to pre-approve an Up Walker. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan follows Medicare rules. Medicare rules say that the Plan may limit DME to only preferred brands and manufacturers as long as the Plan ensures that enrollees have access to all medically necessary (including non-preferred) DME products or brands. 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 Up Walker. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that, based on the medical records provided, there is no documentation that the specific brand of walker that has been requested is medically necessary for you as opposed to the Plan's proposed alternative(s). 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 Up Walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an Up Walker heavy duty walker (E0147).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication Retacrit would likely be less effective, and/or cause adverse effects for the member.
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 Aranesp. Our reviewer says that
Aranesp is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for Aranesp. The patient has not tried and failed the
Retacrit. There is no documentation indicating that Retacrit 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 Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the interrogation device evaluations (93294, 93296) provided on March 10, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $50 copayment for Medicare-covered diagnostic procedures and tests rendered by an in-network provider. You have been asked to pay $49.85 ($27.72 + $22.13) for the diagnostic tests provided. This amount is less than the applicable copayment for these services.
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 adjust the copayment for the interrogation device evaluations (93294, 93296) provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis surgery. 
 
You asked the Plan to pre-approve arthrodesis surgery. You say that this is medically necessary and appropriate 
to achieve sustained pain relief and improve daily activities and quality of life. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because the enrollee has not had a 75% pain 
relief response from previous sacroiliac joint injections. 
 
The plan follows Medicare rules. Medicare rules state that minimally-invasive surgical fusion of the sacroiliac 
joint may be covered under certain clinical criteria. 
 
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 arthrodesis surgery. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested procedure. Our physician reviewer found 
criteria for repeat sacroiliac joint injection therapy are not met, because not enough pain relief is documented 
from previous sacroiliac injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve arthrodesis surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra 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 use of this drug requires a eosinophilic phenotype, defined by an elevated peripheral blood eosinophil level of greater than or equal to 300 cells/MCL in the previous 12 months or greater than or equal to 150 cells/MCL at therapy initiation.
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 treview indicates that the enrollee does not have an eosinophilic phenotype, defined by an elevated peripheral blood eosinophil level of greater than or equal to 300 cells/MCL in the previous 12 months or greater than or equal to 150 cells/mcL at therapy initiation. The documentation does not support that the member has an elevated blood eosinophil level on the submitted laboratory results consistent with severe asthma with an eosinophilic phenotype. Fasenra is not indicated for diagnoses ofunspecified chronic obstructive pulmonary disease and uncomplicated bronchiectasis.
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 Fasenra for the enrollee
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for infection of the right foot and amputation of 4th and 5th toes of the infected foot. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. The patient does require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient 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 not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four levels of medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain 
with axial and radicular components. She has had epidural steroid injections with some relief. The requested 
four levels of diagnostic MBBs is not covered, as the Medicare criteria limit the therapy to two levels per 
session. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four levels of medial branch blocks (MBBs).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services (87506) provided on January 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 87506 is "Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, 
Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 
targets". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of code 87506 is supported by the records provided. Our coding reviewer found that the documentation 
supports that a Gastrointestinal Pathogen Panel was performed, and therefore code 87506 is supported. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (87506) provided on January 4, 2021.  
 
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.