Persius/hicric huggingface dataset:
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and shortness of breath and had testing suggesting likely diagnosis of multiple myeloma. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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 a gastroenterology visit (99204) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network gastroenterology visit. You say that the out-of-network office visit is medically necessary. The Plan denied your request. The Plan says there are network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a gastroenterology visit (99204) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid 100 mcg tablet.

You asked the Plan to pre-approve Synthroid. You say that this request is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid 100 mcg tablet.

Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga tablets.

You asked the Plan to pre-approve Farxiga tablets. You say that the enrollee has already been started on this
medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the
enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga tablets.

Benefits for Farxiga tablets may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency department only if the emergency clinic is affiliated with a hospital. 

We looked at the file and Medicare rules. The emergency facility in this case is a freestanding emergency department that is not affiliated with a hospital. 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 pay for the services provided on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast revision 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 requested procedure is considered cosmetic in nature.

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 the enrollee underwent bilateral reduction mammoplasty in November 2020. The record provided states that the enrollee noticed a breast lump in February 2021. No other information is available. The record also indicates that the enrollee's right breast is now larger than the left breast, the opposite situation of prior to the breast reduction in November 2020. Reshaping of the breasts is a cosmetic procedure under Medicare rules. The rules state that coverage is not available for cosmetic procedures.

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 breast revision for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient visit (99203) and a panoramic jaw x-ray (70355).
You asked the Plan to pre-approve the outpatient visit and panoramic jaw x-ray. The Plan denied your request. The Plan says the Plan says that these services are routine dental care. The Plan also says that routine dental care, such as cleanings, fillings, or dentures are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. The record also shows that the enrollee is not enrolled in the Preferred Dental Option. Therefore, we decided that the Plan does not have to pre-approve an outpatient visit (99203) and a panoramic jaw x-ray (70355).
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for thoracolumbar spinal surgery. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 are 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kisqali, 600 mg, daily dose.

You asked the Plan to pre-approve Kisqali. You say that you need this medication. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kisqali, 600 mg, daily dose.

Benefits for Kisqali may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for an observation hospital stay provided from March 16, 2021, through March 17, 2021.

You asked the Plan to pay for the observation hospital stay. The Plan denied your request. The Plan says your treatment could have been provided at an outpatient level of 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 pay for the observation hospital stay. Our reviewer says that the observation hospital stay is not considered medically reasonable and necessary in this case. Our physician reviewer found that you have a history of Coronary artery disease and your presented to the hospital with chest pain, shortness of breath, diaphoresis, dizziness after an argument. Upon arrival to the emergency department, symptoms had resolved without recurrence. Pulmonary embolism was unremarkable, and your vitals were normal. Your troponin was normal x3. The electrocardiogram/echocardiogram was normal. You were diagnosed with a panic attack. Based on the history and initial workup ruling out acute coronary syndrome or any other acute condition, observation status is not justified and will be considered not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the observation hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for an observation hospital stay provided from March 16, 2021, through
March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of the facet joint.

You asked the Plan to pre-approve the injection. You say that this is medically necesary. The Plan denied your request. The Plan says there is a lack of information on the amount of pain relief from the left-sided diagnostic injections.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there were two setds of intra-articular facet blocks. 60-70% pain relief was achieved. 80% pain relief must be achieved for this request. The criteria is not met, and the request is deemed 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of the facet joint.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lower joint extremity for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a recent six-week trial of doctor-prescribed treatment.
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 not medically reasonable or necessary. Our physician reviewer found there are no red flags to provide an indication for immediate MRI prior to a six week trial of physical therapy. The physical exam showed no effusion or instability. Meniscal signs were listed as +/-. There is no history of trauma and the x-rays are unremarkable. Despite the administration of both intra articular and oral medications the medical necessity for the requested MRI has not been established without a trial of physical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lower joint extremity for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

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 denial of transportation to dialysis after 30 days discharge from the hospital is consistent with the supplemental benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation for up to 30 days prior to discharge from the inpatient hospital or SNF.

The most recent hospitalization ended 5/7/21. The benefit for routine transportation ends 30 days after discharge, which would be 6/7/21. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued home oxygen.

You asked the Plan to pre-approve continued home oxygen. You say that the home oxygen is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mm Hg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

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 continued home oxygen. Our reviewer says that continued home oxygen is medically necessary. Our physician reviewer found the enrollee already uses home oxygen. The records show that oxygen saturation at rest are 87% and down to 78% with activity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home oxygen have been met. Therefore, we decided that the Plan has to pre-approve continued home oxygen.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural injection at L5-S1.

You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that the coverage
criteria are not met.

The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are covered for the
indications established in the applicable LCD.

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 injection. Our reviewer says that the
requested injection is medically reasonable and necessary. Our physician reviewer found that the physician
response indicates 100% pain relief from September 2020 to March 2021. One level bilaterally is medically
reasonable and necessary. One level bilaterally meets the LCD criteria.

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 injection have been met. Therefore, we decided that the Plan has to preapprove
an epidural injection at L5-S1.

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.