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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 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 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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that this enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days. Medicare coverage criteria are not met.

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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex respiratory and medical needs that require ongoing acute care for a minimum of 25 days at the LTACH. The Plan denied your request. The Plan says the denial of LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee require service at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment does not support that the enrollee is reasonably expected to benefit and improve from LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for discharge from the hospital and would benefit from LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the current short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the Plan has stated that continued care in this hospital will be covered. Continued care in the current hospital is appropriate until the enrollee is stable for transfer to a lower level of care such as inpatient rehabilitation, sub-acute rehabilitation, or skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right knee replacement 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 not supported prior to a trial of treatment.

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 was being treated for unilateral primary osteoarthritis, right knee. Progress note cites persistent right knee pain. Exam of the right knee reveals antalgic gait with a limp on the right. There is mild effusion. Tenderness is present. Range of motion is normal. Strength in extension and flexion affected by pain. No instability noted. BMI is noted of 34. X-rays demonstrate medial compartment degenerative changes noted with marked narrowing of the medial joint space with associated subchondral sclerosis and slight varus alignment. However, exam findings demonstrate full motion and strength. Detailed documentation is not evident regarding severe functional deficits. Furthermore, literature does not support this request without prior failure of comprehensive and reasonable conservative treatment (which is not clearly documented to have been trialed and failed for greater than at least 3 months.) There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right knee (partial) replacement is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a right knee replacement for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara System.

You asked the Plan to pre-approve the Volara System. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically reasonable and necessary at this time.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 Volara System. Our reviewer says that The Volara System is not considered medically necessary. Our physician reviewer found this patient has bronchiectasis with a chronic cough, as well as chronic obstructive pulmonary disease, and has reportedly failed clearance therapy with traditional treatments. However, there is insufficient evidence to support the efficacy of the Volara System in treating bronchiectasis or chronic obstructive pulmonary disease.

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 Volara System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara System.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

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 step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic iron deficiency. She has not tried and failed the Plan's required drug, Retacrit. The records do not support that the required drug would be contraindicated or less effective; therefore, the requested Procrit is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery (22869, 22870).

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says the requested surgery is not medically necessary and reasonable.

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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (Intracept procedure).

You asked the Plan to pre-approve Intracept procedure. You say that given the enrollee's history and condition, the Intracept procedure is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Intracept is experimental/investigational.

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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is still considered experimental/investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (Intracept procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 dental fillings.

You asked the Plan to pre-approve dental fillings. You say that you should get 2 fillings this year because you were unable to get 1 filling last year. The Plan denied your request. The Plan says additional fillings are non-covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The file shows that 2 dental fillings were requested. We looked at the file, and Medicare rules. The records show that 1 filling was approved. Your plan benefits only cover 1 filling per year. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional dental filling.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services.

You asked the Plan to pay for the skilled nursing facility services. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's services were custodial.

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 pay for the skilled nursing facility services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary did not require skilled nursing or therapy services on a daily basis. This beneficiary did 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services.
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 you believe the patient is stable and suitable for long term acute care (LTAC) and do not feel he can adequately be cared for in his current condition at a skilled nursing facility (SNF). The Plan denied your request. The Plan says that there is no need for a transfer to a LTACH as the enrollee is currently approved and receiving acute care at their current facility. The Plan states that they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care, or until the clinical circumstances change.

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 that there is no documentation provided that shows admission to an LTACH is necessary. The enrollee is receiving appropriate care at the present acute care hospital. At the time of the request, the member's status is critical and unstable for transfer to LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One syringe.

You asked the Plan to pre-approve Synvisc-One. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria for Synvisc-One Syringe has not been met.

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 Synvisc-One. Our reviewer says that step therapy criteria is not met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's pain is not localized to the facet joint.

The Plan follows Medicare rules. Medicare rules state that facet joint injections are covered under certain indications, including that the pain is not associated with radiculopathy or neurogenic claudication.

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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the rules specifically exclude facet block in the presence of radiculopathy and other probably pain generators. These needs to be addressed before performing facet blocks. Therefore, this request is not considered medically reasonable and necessary at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays, medication administration, and a dental bone graft (D0210, D9612, D7953).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for x-rays has been exhausted and the additional services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the dental benefit does not include coverage for the medication administration (D9612) or bone graft (D7953). The plan has agreed to cover a panoramic x-ray (D0330). X-rays are covered once every three years, therefore, the benefit for X-rays has been exhausted and the intraoral x-rays (D0210) are not covered. Therefore, we decided that the Plan does not have to pay for intraoral x-rays, medication administration, and a dental bone graft (D0210, D9612, D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210) of tooth #'s 3 and 14.

You asked the Plan to pre-approve the extractions. The Plan denied your request. The Plan says the enrollee's history record indicates that these teeth were previously extracted.

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 extractions 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 extractions. Our reviewer says that the extractions are not medically reasonable and necessary. Our physician reviewer found the provided x-rays reveal that there are many missing teeth in the upper arch, including #3 and #14. Our reviewer found that it appears that tooth #1 is present as well as tooth #'s 15 and 16, however tooth #'s 3 and 14 are absent. Our physician reviewer also found that given the fact the requested teeth are not present, there is no medical necessity for the requested removal of either tooth #'s 3 or 14.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210) of tooth #'s 3 and 14.