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 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 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 enrollee required minimal assistance to sit up. The enrollee required contact guard assistance with standing up, sitting down, and walking 55 feet. The documentation does not support that the enrollee requires the intensity of services provided at an IRF. The documentation does not support that the enrollee requires fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the knee
(73721).
You asked the Plan to pre-approve an MRI of the knee. You say that the service 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 MRIs 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 an MRI of the knee. Our reviewer says
that the service is not medically necessary. Our physician reviewer found the submitted records show no red
flags such as instability, trauma or infection to mandate immediate MRI. The notes indicate the enrollee has
been informed of an exercise program but there is no evidence of a referral to physical therapy (PT).
Incidentally, the enrollee has a history of peripheral neuropathy as well. Absent any red flags the medical
necessity of MRI of the right knee at this time has not been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI of the knee have not been met. Therefore, we decided that the Plan does
not have to pre-approve a magnetic resonance imaging (MRI) of the knee (73721).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 21, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression the colonoscopy would be billed as preventive without a copayment. The Plan denied your request. The Plan says the copayment applied correctly.
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 $300 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed, which is considered a surgical procedure. 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 for the colonoscopy provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that a stair lift is medically necessary for the enrollee.
The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's contractual
policy.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers coverage
of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Quetiapine Fumarate 25mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the
member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Quetiapine Fumarate
25mg tablet medication.
Benefits for this medication 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell injections (Palingen or Promatrx) for the
enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not have a covered indication.
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 injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found stem cell injections
have been requested to treat bilateral osteoarthritis of the knees. This is not a medically accepted indication for
stem cell injections.
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 stem cell injections (Palingen or Promatrx) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva 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 the clinical criteria for coverage is not met.
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 although Prolia, which is the same chemical as Xgeva, is indicated for osteoporosis in men with non-metastatic prostate cancer, Xgeva is not FDA indicated or compendium supported for the requested use. Therefore the documentation does not support that the drug is medically reasonable and necessary nor that it is safe and effective 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 Xgeva for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service the enrollee fell and suffered a traumatic brain injury. You say that the responding emergency services determined that the enrollee was not stable enough for ground transportation and called for an air ambulance service, which transported the enrollee to the hospital. You stated that although the ground ambulance responders did not transport the enrollee, they were an essential part of the emergency response team. You say that they initiated life saving measures and coordinated the air transportation. You asked the Plan to reconsider their denial and provide coverage.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ground ambulance company did not provide transport services on October 30, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor thePlan pays for the services provided. Therefore, we decided that the Plan does not have to pay forthe ambulance 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 clinical documentation provided supports the
need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage 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 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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
with regular physician evaluation. The enrollee's care needs can be met at a lower 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimmediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction and mastopexy.You asked the Plan to pre-approveimmediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction and mastopexy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plansays the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that immediate insertion of breast prosthesisis considered cosmetic, and therefore, not a covered benefit.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 immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction and mastopexy. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have a history of bilateral augmentation mammaplasty and now have evidence of implant rupture on the right side. This is supported by mammographic documentation. Plastic surgery documentation from September 20, 2016 notes that you have evidence of a leakingimplant and that a recommendation is for implant removal with or without a mastopexy. The requested services are considered cosmetic treatment. Therefore, you do not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. The plan has approved the surgery for the removal of the old breast prosthesis. Based on this information, we decided that Medicare rules for coverage of immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction and mastopexy have not been met. Therefore, we decided that the Plan does not have to pre-approveimmediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction and mastopexy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee 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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for observation hospital care provided June 2, 2019.
You asked the Plan to waive the deductible and copayment for the observation hospital care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment and deductible 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 $125 copayment after the $750 deductible is met for observation care. You have been asked to pay a $125 copayment and a $750 deductible for the observation hospital care. 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 deductible and copayment for observation hospital care provided June 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says alternate settings can be reviewed, such as skilled nursing facility (SNF), outpatient
setting, or home 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 enrollee nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled
physical therapy and occupational therapy but based on the medical records provided the enrollee does not
require treatment in an intensive rehabilitation therapy program. There is concern that the enrollee would not be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this
case.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. It is not clear that you would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more appropriate. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services and injections of Vitamin B-12 cyanocabalamin, pyridoxine hydrochloride, thiamine hydrochloride, and other unlisted Medicare Part B drugs provided on November 11, 2019.
You asked the Plan to pay for outpatient rehabilitation services and Part B drugs. You say that you are appealing for payment. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered, not medically necessary, or were experimental/investigational in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The rules say that Medicare covers a drug or biological only if it 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 pay for outpatient rehabilitation services and Part B drugs. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support that the therapies or injections provided were medically reasonable or necessary to treat the enrollee's chronic pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient rehabilitation services and Part B drugs have not been met. Therefore, we decided that the Plan does not have to pay for outpatient rehabilitation services and injections of Vitamin B-12 cyanocabalamin, pyridoxine hydrochloride, thiamine hydrochloride, and other unlisted Medicare Part B drugs provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a skin substitute for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary to help expedite
treatment of chronic venous ulcers. The Plan denied your request. The Plan says that the enrollee's condition
could be treated with adequate compression, checking, and treating wound.
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 procedure. Our reviewer says that
the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer
found the skin substitute at issue in this case are medically reasonable and necessary, because EpiFix is the
standard of care for such ulcers and should be restarted in 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 the procedure have been met. Therefore, we decided that the Plan has to preapprove
a skin substitute for the enrollee.