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

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 30, 2020, through August 10, 2020.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay 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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from July 30, 2020, through August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medicallynecessary, 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 topre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.The enrollee can remain at the current ACH until such time no acute services are required.The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the
acute care hospital where she is currently receiving care. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second set of medial branch blocks.
You asked the Plan to pre-approve the medical branch blocks. You say that you would like reconsideration
because the member has experienced 65% pain relief. The Plan denied your request. The Plan says the records
do not indicate that there was adequate pain relief from the initial injections.
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 medical branch blocks. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the LCD requires that 80% pain relief be achieved. This result should be
interpreted as negative and alternative pain generators should be examined.
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 medical branch blocks. have not been met. Therefore, we decided that the
Plan does not have to pre-approve a second set of medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Privigen IVIG.
You asked the Plan to pre-approve the drug. You say that this is the only medication that shows signs of
progress. The Plan denied your request. The Plan says that the enrollee does not have a covered indication for
treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found that in this case, you have
been treated with Privigen IVIG for 2-3 years with documented positive effect. The review has determined that
the documentation supports that Privigen is medically reasonable and necessary. Privigen will be safe and
effective for you.
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 drug have been met. Therefore, we decided that the Plan has to pre-approve
Privigen IVIG.
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: 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 IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different 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 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 do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like reconsideration because the member exceeds the CMS established criteria for an appropriate LTACH admission.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.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 as LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there are step therapy requirements.

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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, the enrollee has not tried and failed the required drugs. There is no indication that the plan's
required drugs 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Epogen for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not the standard of care for prostate cancer.
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 therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found to date, there is no compelling data to suggest that proton therapy is superior to or more beneficial than
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy
on clinical trials, and to not routinely offer it to patients.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve proton beam radiation therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided for the enrollee from February 12, 2021, forward. You asked the Plan to pre-approve continuation of inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. 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 continuation of inpatient mental health care. Our physician reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 12, 2021, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided for the enrollee from February 12, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5226, D9230) 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 these are not covered services.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D5226, D9230) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous passive motion (CPM) device.You asked the Plan to pre-approvea CPM device. You say that the enrollee is unable to have physical therapy for the first sixweeks post-surgery, he needs this device to help him move shoulder after complete shoulder replacement.The Plan denied your request. The Plan says Medicare states that continuous passive motion machines are nationally only covered after total knee replacement surgery.The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery.You are not inquiring to use after total knee replacement surgery.Therefore, we decided that the Plan does not have to pre-approvea continuous passive motion (CPM) device
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of Fasenra for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no medical record documentation showing that this medication is providing a
benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found in this case, there is no
medical record documentation that the medication is providing a health benefit to the enrollee. Specifically,
there is no documentation showing continued disease improvement or lack of disease progression, and there is
no documentation that the enrollee is not experiencing toxicity from the medication.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of Fasenra for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea facet joint injection.You asked the Plan to pre-approvea facet joint injection. You say that the requested facet joint injection is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested facet joint injection.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 a facet joint injection. Our reviewer says that the enrollee does not meet criteria for the requested facet joint injection. Our physician reviewer foundthe enrollee has spinal stenosis with neurogenic claudication and bilateral sacroiliitis. The enrollee has had physical therapy and takes oxycodone and Flexeril for pain. She had SI joint injections. The request is for therapeutic, not diagnostic facet joint injections. She has not had epidural steroid injections. The enrollee has multiple pain generators other than her facet joints. Therefore, she does not meet the criteria of the LCD and 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 a facet joint injection have not been met.Therefore, we decided that the Plan does not have to pre-approveafacet joint injection
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs. The enrollee required minimal to moderate assistance with functional mobility. The enrollee required varying assistance with activities of daily living. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) multi-seat function control (E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that you would like reconsideration because these accessories are medically necessary. The Plan denied your request. The Plan says neither Medicare nor the Plan cover the requested items.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessories have not been met. Specifically, per Medicare, the power seat elevation and electric connection are non-covered as they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300) multi-seat function control (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dental services with dental codes D2950, D3120, and D9910.You asked the Plan to pre-approvedental codes D2950, D3120, and D9910. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says dental codes D2950, D3120, and D9910 are not covered under the supplemental dental benefit.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 requested dental codes D2950, D3120, and D9910 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe dental services with dental codes D2950, D3120, and D9910.