Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.You asked the Plan to pre-approve8 additional PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 8 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found for back pain, PT is generally accepted as specific and effective therapy. Goals include reducing pain, restoring function, and educating regarding a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve8 additional physical therapy (PT) visits.
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. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of IRF care.
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 patient was medically stable with no evidence of need for supervision by a
rehabilitation physician or needs acute rehab nursing care. The patient may benefit from further therapy but
does not require an intensive therapy program. IRF admission is not medically necessary based on the patient's
current functional status and medical stability.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
You asked the Plan to pre-approve the lumbar/sacral facet joint radiofrequency neurolysis. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the notes sent do not say why the enrollee needs this done now. The Plan says that there are no notes showing a how the last procedure worked for the enrollee.
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 lumbar/sacral facet joint radiofrequency neurolysis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had 4 prior lumbar epidural steroid injections and 2 sets of lumbar facet joint blocks with local anesthetic and steroids. the degree of pain relief for each set is not documented. The degree of pain relief from each set of diagnostic blocks must be clearly documented to exceed 80%. 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 lumbar/sacral facet joint radiofrequency neurolysis have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that this is medically necessary due to your spinal injury.The Plan denied your request. The Plan says you could be treated at a lower level of care.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 rulesto 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 show that you are medically stable with no evidence of a need for physician supervision or acute rehab nursing care. Functionally, you do not require IRF level of therapies. You may benefit from further physical and occupational therapy, but you do not require an intensive therapy 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvePET scan from head to thighs for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medicallynecessary.The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found CMS guidelines provide strict criteria for PET imaging which includes a diagnosis of malignancy or strongly suspicious of same. This enrollee has no mass on physical exam and no adenopathy identified. While there is a prior history of radiation therapy for breast cancer there is no mention in the records of radiation therapy to the neck and no adenopathy on physical exam. Also, thelaryngoscopy demonstrated bilateral hypertrophy of the lingual tonsils and no additional findings such as mass, induration etc. In addition, no conventional imaging such as CT or MRI has been done in order to evaluate the neck. The medical necessity for PET/CT at this time is not established with the records provided.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvePET scan from head to thighs for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical insertion of an interspinous process stabilization device.
You asked the Plan to pre-approve interspinous stabilization device. You say that his procedure would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's body-mass index is above the limit for coverage of this procedure.
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 interspinous stabilization device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental/investigational and more research is needed to show the safety and efficacy of this procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous stabilization device have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical insertion of an interspinous process stabilization device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested out-of-network services are not a medical emergency.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of LTACH services. 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 enrollee was admitted and treated for a gastrointestinal bleed due to angiodysplasias via endoscopic intervention. Also wound care was continued including using a wound VAC to the left foot and a fem-pop bypass was performed. Following these procedures, the enrollee was recovering and is stable, requiring the wound VAC, physical therapy, and monitoring. 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 acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee meets the Medicare criteria for IRF service.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 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. At the current level of function, the enrollee does not require treatment by multiple therapies and an intensive rehabilitation therapy program. The enrollee will not be able to make a significant functional recovery within a predicted period of time from an IRF. The enrollee's rehabilitation needs can be met at a lower intensity level of care such as a skilled nursing facility or home health 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 services.You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the SNF services are medically necessary.The Plan denied your request. The Plan says you would benefit from less than daily skilled therapy in the custodial setting.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 your rehab needs can be met at a lower intensity setting such in-home with services or in long term care with occasional therapies.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 services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A9270.
You asked the Plan to pre-approve the compression stockings. You say that you require these stockings to help with leg swelling. The Plan denied your request. The Plan says compression stockings described by this code are a non-covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A9270 are noncovered. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A9270.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BROVANA.
You asked the Plan to pre-approve BROVANA (J7605). You say that the enrollee has tried other drugs with poor control. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to PERFOROMIST.
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 BROVANA (J7605). Our reviewer says that the drug is not medically necessary. Our physician reviewer found coverage criteria for BROVANA are not met. The Plan requires a trial of PERFOROMIST, an alternative nebulized long-acting beta agonist, which the enrollee has not tried. PERFOROMIST would be expected to have equivalent effects. Therefore, BROVANA is considered not medically necessary, and the denial is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BROVANA (J7605) have not been met. Therefore, we decided that the Plan does not have to pre-approve BROVANA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that the enrollee requires this to aid in leg swelling because the leg veins are not working well.The Plan denied your request. The Plan says you do not have an open venous ulcer;therefore,these are not covered.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an injection (62284), epidurography(72275), contrast material (Q9966), surgical trays (A4550), and sedation services (99156, 99157) provided on December 17, 2019.You asked the Plan to pay for an injection, epidurography, contrast material, surgical trays, and sedation services. You say that this provider is certified and eligible for payment.The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare payment.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not shown that the provider at issue was precluded from Medicare payment for the dates of service at issue. The Plan has provided screenshots of a list, but it is unclear from the screenshot if it is the Medicare Preclusion list (there are no headers and the screenshot itself does not have an indication as to where this information came from). Without this information, we are unable to verify that the provider at issue was precluded from Medicare payment for the dates of service at issue.Therefore, we decided that the Plan has to pay foran injection (62284), epidurography (72275), contrast material (Q9966), surgical trays (A4550), and sedation services (99156, 99157) provided on December 17, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BROVANA.
You asked the Plan to pre-approve BROVANA (J7605). You say that the enrollee does not have the lung
capacity to inhale regular inhalers. The Plan denied your request. The Plan says the enrollee has not first tried
and had a contraindication or intolerance to PERFOROMIST.
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 BROVANA (J7605). Our reviewer says
that the drug is not medically necessary. Our physician reviewer found coverage criteria for BROVANA are
not met. The enrollee has not tried PERFOROMIST, an alternative nebulized long-acting beta agonist that is
favored by the Plan. It is expected that PERFOROMIST would be safe and as effective for the enrollee.
Therefore, BROVANA is considered not medically necessary, and the denial is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BROVANA (J7605) have not been met. Therefore, we decided that the Plan
does not have to pre-approve BROVANA.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 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 there is no longer a need to stay at this facility. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is stable and ambulating. There are no noted daily complex skilled nursing needs. While she may be expected to benefit from continuing PT and OT, the records do not support a 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.