Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea shower chair.You asked the Planto pre-approvea shower chair. You say that this is necessary for the enrollee to complete daily living activities.The Plandenied your request. The Plansaysthis is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical stimulation neuropathy.You asked the Plan to pre-approve the electrical stimulation neuropathy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is 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 the electrical stimulation neuropathy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the proposed therapy would be considered to be investigational in nature and thus not eligible for coverage.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 electrical stimulation neuropathy have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical stimulation neuropathy.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp infusions.You asked the Plan to pre-approvethe Aranesp treatment. You say that you feel that the Aranesp should be approved since the hospitals and clinics in the area do not carry Retacrit.The Plan denied your request. The Plan says Retacrit is available for mail order from network specialty pharmacies. This drug is required as step therapy in order for Aranesp to be approved.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Aranesp treatment. Our reviewer says that the requested Aranesp is not considered reasonable and necessary due to step therapy requirements. Our physician reviewer found the enrollee is a female with chronic kidney disease and anemia. The records do not support a failure of the preferred drug, Retacrit. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. In addition, review of the FDA Drug Shortages website does not indicate there is any current shortage of the drug Retacrit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the Aranesp treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp infusions
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 due to your condition you need physical therapy to move around. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 you are currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician 3 times per week or acute rehabilitation nursing care. While you may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive rehabilitation therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plandenied your request. The Plan says the SNF admission is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are receiving care that can be provided by his non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. Your condition would not be expected to deteriorate with services provided on a less than daily 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy (PT) to be provided by the out of network (OON) provider.
You asked the Plan to pre-approve the OON PT services. You say that the OON provider uses different types of therapy which have been more helpful than those provided by the network provider. You feel you should be allowed to continue with the OON provider. The Plan denied your request. The Plan says there is no evidence that the services from the in-network provider are less effective than the OON provider.
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. [Provider Name] is not a network provider with the Plan. 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 OON PT services. Our reviewer says that the documentation does not support the medical necessity of the OON provider. Our physician reviewer found the documentation does not support that it is medically reasonable and necessary to continue care with OON provider rather than returning to a network PT. There is no objective evidence that indicates that the out of network provider is more beneficial than an existing and available medically appropriate alternative. There is no objective evidence that the out of network therapy is more effective than an in network therapist. Additionally, the patient has had extensive supervised PT for this condition and the documentation does not clearly reveal that she requires the ongoing professional skills of a therapist rather than transitioning to an independent home exercise program. 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 OON PT services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the OON PT services. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy (PT) to be provided by the out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT Scan of the head and brain (70470).
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested CT Scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that you do not meet Medicare coverage criteria for the CT Scan. Our physician reviewer found you have not noted any neurologic complains and the physical examination did not note and neurologic findings. There are no signs, symptoms or an established protocol based on the review of your old records. 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 CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT Scan of the head and brain (70470).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) for the upper left and upper right quadrants to be provided by "the doctor".You askedthe Plan to pre-approvethe dental services. You say that you do not want to wait until your teeth fall out to have preventive care.The Plan denied your request. The Plan says the documentation does not show that you have a large amount of bone loss or build up on the teeth that shows on an x-ray for 4 or more teeth per section of the mouth.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 dental services 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the documentation provided shows noticeable bone loss is only seen around two teeth on the upper right quadrant and one tooth in upper left. The criteria for D4341 requires 4 teeth per quadrant to qualify for the requested procedure, therefore the requested dental services are not medical necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rulesfor coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) for the upper left and upper right quadrants to be provided by "the doctor".
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 enrollee meets the criteria for IRF care based on her medical condition and ability to benefit from three hours of daily therapy. The Plan denied your request. The Plan says the enrollee does not require frequent physician care or intensive rehab.
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 enrollee is a female who was admitted to the hospital on 1/7/2020 with shortness of breath. She was found to have UTI, C. diff colitis, and atrial fibrillation with RVR. 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMRI of the pelvis.You asked the Plan to pre-approve the MRI. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the MRI is not medically necessary.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 [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found MRI of the pelvis is not the appropriate test for your diagnosis.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 pelvis.
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-approveIRF care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the IRF admission 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 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 records do not indicate that there are significant or complex medical/nursing issues that could not be addressed at a Skilled Nursing Facility level of care. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and can be treated at a lower 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 treatment. Our reviewer says that the requested treatment is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 9, 2020 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health treatment for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s).You asked the Plan to pre-approve midface flap with preservation of vascular pedicle(s). You say that this will be an effective treatment. The Plan denied your request. The Plan says this service is cosmetic.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 midface flap with preservation of vascular pedicle(s). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the Midface flap is medically reasonable and necessary for the enrollee in this case. Further studies with larger series of patients and a control group are encouraged to fully determine the permanence of the subperiosteal midface lifting procedures and the advantages that the different surgical approaches can offer.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of midface flap with preservation of vascular pedicle(s) have not been met.Therefore, we decided that the Plan does not have to pre-approve midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approve the admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee can continue PT/OT safely in a lower level of care, such as home with home health services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee oes 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOxycodone tablets.You asked the Plan to pre-approveself-administered drugs. You say that it is important that the enrollee receive adequate pain relief for her condition, and this drug will provide the best outcome and quality of life.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's prescription drug benefits may be administered by Silver Scripts.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 nothave to pre-approveOxycodone tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe 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-approveErleada tablets.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee is stable on samples of this drug.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. This drug does not meet the exception for Part B coverage of a self-administered drug, because it does not have the same active ingredients and usage as a covered non-self-administrable anti-cancer drug or biological. 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-approveErleada tablets.Benefits for self-administered drugsmay be available under Medicare PartD.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.