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

We decided that the Plan does not have to pre-approvelumbar decompression spinal surgery for the enrollee.You asked the Plan to pre-approvelumbar decompressionspinal surgery. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 lumbar decompression spinal surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of spinal stenosis. The documentation supports that more conservative measures are needed. There must be a recent and adequate trial and failure of physical therapy. Therefore, the enrollee does not meet criteria for the requested surgery.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar decompression spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar decompression spinal surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services the enrollee. You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for thediagnosis 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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. All medically necessary care is being provided in the current acute care setting. 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 health plan has approved ongoing care in the current acute care setting. 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer device
You asked the Plan to pre-approve the requested services. You say that the service will restore function, improve quality of life, and relieve pain. The Plan denied your request. The Plan says the requested service is contraindicated due to a prior lumbar fusion and pronounced scoliosis.
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 requested spacer remains experimental. More research is needed to show safety and efficacy of the device. Therefore, the requested services are not medically reasonable and 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 a Vertiflex interspinous spacer device
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee needs assistance for daily living.The Plan denied your request. The Plan says the enrollee can receive skilled therapy and nursing on an intermittent basis.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 physician reviewer found that the enrollee is independent for sit-to stand and transfers, and at contact guard assist for ambulation using a rolling walker. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 coverageof SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra intravenous (IV) infusions.
You asked the Plan to pre-approve Actemra. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Actemra. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the requested use of Actemra is not FDA-approved for the enrollee's diagnosis. Actemra is FDA approved for use by subcutaneous administration for the patient's diagnosis of giant cell arteritis. However, the request is for intravenous administration of Actemra which is not FDA approved for use for giant cell arteritis. The use of Actemra by IV route for giant cell arteritis is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra intravenous (IV) infusions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that home blood pressure monitors (A4660) and home blood pressure cuffs (A4663) are considered home dialysis supplies. These items are only covered for patients on home dialysis. You can find this rule in the Medicare Claims Processing Manual, Chapter 8, Section 90.3.2(A).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you feel that the previous injection was starting to work, but you did not get a chance to see if it worked. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you did not have a noticeable improvement in knee pain or function after your previous injection.
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 Synvisc One. Our reviewer says that you do not meet the Medicare criteria for a repeat injection of Synvisc One. Our physician reviewer found there is no clear documentation of the degree of improvement after your first injection. This injection is also not recommended by the American Orthopaedic Academy at this time due to research showing a lack of efficacy. Therefore, the requested Synvisc One is not clinically indicated 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 Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androderm transdermal.
You asked the Plan to pre-approve the Androderm. You say that this is needed for his condition. The Plan denied your request. The Plan says this is a self-administered medication and is not covered by 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 Androderm transdermal.
Benefits for the Androderm 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approvecontinued services. The Plan denied your request. The Plan says the services you are receiving do not require a skilled therapist or nurse to meet your needs.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 continued services. Our physician reviewer found that your current level of function is ambulating 40 feet with a rolling walker with moderate assist, moderate assist with bed mobility, minimal assist with upper body activities of daily living (ADLs), minimal assist with lower body ADLs, and maximal assist with toileting. You have not been participating in therapy. You have a sacral wound which is cleansed and treated with nystatin powder and barrier cream. There are no noted daily skilled complex nursing needs. While you may benefit from continuing physical and occupational therapy, the records do not support the need for daily 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, positron emission tomography (PET) scan (78608).
You asked the Plan to pre-approve a PET scan. 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 follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and fronto-temporal dementia (FTD). 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 PET scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no record of complete neuro cognitive testing and nowhere in the records is there discussion of FTD versus Alzheimer dementia. These are necessary factors for coverage of PET scans.
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 PET scan have not been met. Therefore, we decided that the
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis (27280).
You asked the Plan to pre-approve arthrodesis. You say that you would like reconsideration as this service is medically necessary. The Plan denied your request. The Plan says the member does not meet criteria for coverage of this service.
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 arthrodesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of SI joint instability, fracture or tumor. SI joint fusion for degenerative back pain is experimental. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis (27280).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
You asked the Plan to pre-approve the transthoracic echocardiogram. You say that a transthoracic echocardiogram is needed as a follow-up study and is considered standard treatment by the medical community. You say that the requested test is medically necessary. The Plan denied your request. The Plan says the requested service did not meet the medical necessity standards.
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 transthoracic echocardiogram. Our reviewer says that a transthoracic echocardiogram is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has hypertension with well controlled blood pressure. The enrollee had a reported normal electrocardiogram without left ventricle hypertrophy and a prior echocardiogram with "no increase in wall thickness". In this circumstance, in the absence of any documented clinical change, the records do not support the medical necessity for a repeat echocardiogram. 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 transthoracic echocardiogram have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting, or home care.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 continues to require acute level of care hospital services and is receiving appropriate care at the present acute care facility. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
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 medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly MODERATE to MAX assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or participate in an IRF 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 laparoscopy (43775).
You asked the Plan to pre-approve the laparoscopy. You say that you would like reconsideration as this service is medically necessary. The Plan denied your request. The Plan says the member has not tried and failed conservative therapies for weight loss and their BMI is not greater than 35.
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 laparoscopy. Our reviewer says that the member does not meet LCD criteria for failure to document a BMI that is greater than 35. Our physician reviewer found the documentation does not include failed medical efforts at weight loss.
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 laparoscopy have
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar epidural injection
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says that the notes do not show any positive findings on exam to support another injection. There is no documentation of radicular symptoms noted.
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 service. Our physician reviewer found that you had greater than 50% pain relief for 10 weeks after your epidural steroid injection on November 11, 2019. You have continued your home exercise program and your medications. The pain complaints are the same as before your previous injection. You meet all of the LCD criteria. Therefore, the injection is medically reasonable and 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 service have been met. Therefore, we decided that the Plan has to pre-approve a lumbar epidural injection