Persius/hicric huggingface dataset:
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a history of stroke, diabetes and hypertension, who underwent surgery for a left femur fracture. The physician documents a disposition of "SNF most likely" on 7/27/20. Based on the records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee is generally medically stable and the documentation does not support that she has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehab physician three times per week. While the enrollee may benefit from continuing physical therapy and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurosurgery referral.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 medical records do not show documentation that at least six weeks of physical therapy were done.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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found in such a case, in the absence of any markedly focal neurological findings on examination (not present in this case), it would not be readily consistent with the generally accepted standards of practice to refer a patient for surgical evaluation. Rather, surgery is generally reserved as a "last resort" when conservative therapies are not sufficient for the management of a patient's condition. Even after consult with a surgeon a patient is generally directed to other forms of non-operative therapy prior to a physician offering a surgical intervention. Referral directly to a surgeon at this time would also carry the appearance of being for the convenience of the enrollee and would otherwise exceed his clinical needs at this time. As such the service would not be considered 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 the referral have not been met.Therefore, we decided that the Plan does not have to pre-approve a neurosurgery referral.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this is denied as it is the non-preferred product, and there is no evidence of a trial of a
non-preferred product.
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 injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found you have not tried
and failed the preferred required drugs. Based on the medical records provided there is no indication that the
plan's required drugs would likely be less effective and/or likely have adverse effects 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve Genvisc injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen 10,000 units/ml vial.You asked the Plan to pre-approveEpogen10,000 units/ml vial. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy andwill be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Epogen 10,000 units/ml vial.Benefits for Epogen 10,000 units/ml vialare available under the enrollee's Medicare Part D plan.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Perforomist.
You asked the Plan to pre-approve Perforomist. The Plan denied your request. The Plan says this drug is not
medically necessary.
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 Perforomist. Our reviewer says that
Perforomist is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer
found that the enrollee is on the Trelegy inhaler, which contains a LABA. Addition of a second LABA is
contraindicated because of duplicate therapy and potential for excessive dosing of the beta agonist. The clinical
notes provided do not mention this medication, raising the question of whether there has been an error involved
in the order. Perforomist is not medically reasonable or 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 Perforomist have not been met. Therefore, we decided that the Plan does not
have to pre-approve Perforomist.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a home sleep apnea test.You asked the Plan to pre-approve a home sleep apnea test. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for certain indications.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 home sleep apnea test. Our reviewer says that the documentation supports that the requested sleep study is medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of obstructive sleep apnea (OSA) (a condition for which Medicare covers diagnostic sleep testing). The enrollee is known to have OSA (based on the results of prior sleep testing). The enrollee was reportedly intolerant of CPAP, but the enrollee's providers want to restart the enrollee on a therapy. The enrollee is already noted to have been diagnosed with OSA (and prior test results were available). This would subsequently preclude the enrollee's eligibility to receive DME services related to OSA. It is reasonable and necessary to have the enrollee undergo a repeat diagnostic study, as there was a face to face visit completed before this study was ordered. Therefore, the enrollee meets criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home sleep apnea test have been met.Therefore, we decided that the Plan has to pre-approve a home sleep apnea test.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 Plandoes not haveto pre-approveProlia for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information submitted doesn't meet the medical necessity guidelines for coverage.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 Zoledronic acid is just as effective. The enrollee has not tried and failed Zoledronic acid. Zoledronic acid is the most potent bisphosphonate available. There is no documentation provided indicating that the plan's required drug 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 Plandoes not haveto pre-approveProlia for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetamin.You asked the Plan to pre-approve Hydrocodone-Acetamin. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Hydrocodone-Acetamin.Benefits for Hydrocodone-Acetamin 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 pre-approve bilateral sclerotherapy for symptomatic varicose veins.
You asked the Plan to pre-approve the requested sclerotherapy. You say that this treatment is necessary to
reduce varicose vein symptoms. The Plan denied your request. The Plan says medical necessity criteria for
these services are not me.
The Plan follows Medicare rules. Medicare rules say that sclerotherapy for symptomatic varicose veins is
considered reasonable and necessary when the above criteria are met.
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 requested sclerotherapy. Our
reviewer says that the requested treatment is not considered reasonable and necessary based on LCD
guidelines. Our physician reviewer found the documentation does not support the medical necessity of the
treatment in question. The patient has already undergone bilateral vein ablation and bilateral stab
phlebectomies, in addition to sclerotherapy on the right. It is not documented that the patient is having life style
or mobility limiting symptoms that persist despite the regular use of compression stockings. There is
documentation that there is the coexisting etiology for the patient's symptoms, deep vein reflux, that is
generally managed with compression stockings.
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 requested sclerotherapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve bilateral sclerotherapy for symptomatic varicose veins.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the services you received on March 3, 2020, and March 17, 2020.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this provider is not enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The requested provider was not enrolled in the Medicare program on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan does not have to pre-approve the services you received on March 3, 2020, and March 17, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an implant for the first metatarsophalangeal (MTP) joint.
You asked the Plan to pre-approve the implant. You say that this service has literature support and is
shown to be similarly helpful in relieving pain as the standard treatment. The Plan denied your request. The
Plan says that this service has a Hayes rating which indicates that the findings are inconclusive. The one study
available does not show clear benefit to the inplant over arthrodesis. As such, this cannot be considered reasonable
and necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 implant. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found Medicare guidelines advise that Medicare will pay for a treatment to improve the functioning of
a malformed body member. The criteria for this treatment includes that it is safe and effective, not mainly for
the convenience of the patient or the physician, not experimental or investigational, and appropriate with
regards to the accepted standards of medical practice with a diagnosis or treatment of the patient's condition.
The implant is one of the newest types of implants to treat hallux rigidus. The implant is indeed
FDA approved, with studies to support its effectiveness. Implants to the first MPJ have their pros and cons, and
are commonly compared to an arthrodesis. Studies show that the implants can be
very effective in alleviating the patient's pain.
It is well documented that this patient is suffering with painful hallux rigidus right side unresponsive to
conservative care. X-rays demonstrate osteophytes surrounding the first MPJ. The implant for this
patient's hallux rigidus can be considered medically reasonable and 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 implant have been met. Therefore, we decided that the Plan has to
pre-approve an implant for the first metatarsophalangeal (MTP) joint.
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 long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing
care needs include respiratory support with intermittent ventilator management and weaning, surveillance
laboratory studies, hemodialysis, buttock wound, tube feedings, and therapy services. The documentation does
not support that the enrollee in this case requires services at the LTACH that are not available at the acute care
hospital where he is currently receiving care. There are no required medical services identified that are
available at the LTACH, that are not available at the current health care setting being offered by the health
plan. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance transport (A0427) provided November 28, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the copayment should be waived because this was an emergency. You used the services in the past and were not billed.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Ambulance Services. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ambulance transport (A0427) provided November 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa Injections (J7323).
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied
your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for Euflexxa to be covered, the enrollee must
show no improvement from corticosteroid injection therapy.
We looked at the file and Medicare rules. The records do not show that corticosteroid injections on March 12,
2020 did not relieve the enrollee's pain. Based on this information, we decided that Medicare rules for coverage
of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa
Injections (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1851).You asked the Plan to pre-approve the knee brace. You say that the brace is medically necessary.The Plan denied your request. The Plan says they have already provided several braces. A new brace cannot be covered because the previous one is still within it's useful lifetime.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of custom fabricated orthosis is 3 years. We looked at the file and Medicare rules. The record shows the same type of brace was previously provided within the last 3 years. There is no documentation to show it was lost or irreparably damaged. Based on this information, we decided that Medicare rules for coverage of the knee brace have not been met.Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1851).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation
trips exceed the benefit limit. Therefore, coverage criteria has not been met.
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 a maximum of 48 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).