Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane viscosupplementation injections.
You asked the Plan to pre-approve the Durolane injections. You say that this is a necessary treatment for the enrollee's condition. The Plan denied your request. The Plan says a trial of Orthovisc or Monovisc is required.
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 Durolane injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has not trialed preferred viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Durolane is not approved, as step criteria have not been 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 the Durolane injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane viscosupplementation injections
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet joint injection.
You asked the Plan to pre-approve facet joint injection. 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 has not undergone 2 diagnostic facet joint procedures.
The Plan follows Medicare rules. Medicare rules state that facet joint injections are considered medically reasonable and necessary for enrollees who meet certain criteria. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet joint injection. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint intervention.
Our physician reviewer found the enrollee has radiculopathy, which does not meet the coverage indications for
the requested facet joint injection.
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 injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve a facet joint injection
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on April 23, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist in a home health or hospice setting.
This means there is a more appropriate code to be billed for the services rendered. Based on this information,
we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we
decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on April
23, 2020.
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 IRF care is medically necessary, and the enrollee's condition will continue to decline without these services. The Plan denied your request. The Plan says the enrollee's necessary care is routine and does not require a team of providers. The criteria for an IRF are not met, and the enrollee can safely receive the necessary care in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the necessary care can safely be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract removal surgery.
You asked the Plan to pre-approve cataract removal surgery. You say that the enrollee is blind and has blurry vision in her eyes. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for this procedure.
The Plan follows Medicare rules. Medicare rules state that cataract removal may be covered under certain clinical conditions. 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 cataract removal surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested cataract surery. Our physician reviewer found the documentation does not support that the enrollee has impairment of visual function due to cataract(s) and a decreased ability to carry out activities of daily living. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cataract removal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract removal surgery
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 3, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no authorization on file for the services rendered.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The file shows that the enrollee was seen for the evaluation and management of psoriasis. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 3, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 Benlysta.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on January 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, there is no documentation for the billed date of service. 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 pay for the physical therapy
services rendered on January 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on May 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unable to get the authorization before the services. The Plan denied your request. The Plan says there is no authorization on file for the services.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The file shows the enrollee was seen for a follow-up visit for back pain. The provider in this case is not a
network provider with the Plan. The Plan had network providers available who could have provided the
services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that
would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for
the pain management services provided on May 12, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on April 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on April 13, 2021.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you were the only practice in the area that was able to treat the enrollee. The Plan denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 9, 2020 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage (A0170).
You asked the Plan to pre-approve additional transportation mileage. You say that you want the Plan to pre-approve additional transportation mileage so you can have surgery on your eye. The Plan denied your request. The Plan says the routine transportation benefit only allows each one-way trip not to exceed 50 miles.
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 up to 24 one-way trips per calendar year. Each one-way trip must not exceed 50 miles. We looked at your request, the records in the case file, and the rules. 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 transportation mileage (A0170).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided January 14, 2020 to February 25, 2020.
You asked the Plan to pay for the psychotherapy services. You say that these services were medically necessary and should be covered. The Plan denied your request. The Plan says this provider is not enrolled in the Medicare program and was unable to provide records or credentials to support the services billed.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided January 14, 2020 to February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your request. The Plan says this use is experimental.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Rituxan. Our reviewer says that the requested use of Rituxan is not supported. Our physician reviewer found the requested use of Rituxan is not Food and Drug Administration-approved for the enrollee's diagnoses and is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is no documentation that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar Intracept procedure.
You asked the Plan to pre-approve Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). You say that the science supporting this treatment is far greater than many other procedures the Plan provides coverage for. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and effective.
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 Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. Therefore, the request is considered 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 Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar Intracept procedure