Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the requested bed. You say that you are trying to prevent ulcers. The Plan denied your request. The Plan says the service is non-covered.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for out-of-network home health services.

You asked the Plan to pre-approve an in-network exception. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance from the enrollee's location.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be higher.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve an in-network exception for the requested services. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for out-of-network home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.

You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are medically necessary. The Plan denied your request. The Plan says the requested medial branch blocks are not medically necessary.

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 medial branch blocks. Our reviewer says that the requested medial branch blocks are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He is taking Gabapentin for pain. He had a Spinal Cord Stimulator placed and his leg pain is improved but his axial back pain remains. There is no documentation of any re-programming attempts. The enrollee is status post a spinal fusion, but the exact levels are not documented. The request is for diagnostic MBBs. There is no physical exam documenting facet dysfunction.

The request does not meet LCD criteria including a lack of Physical exam findings and probable prior fusion surgery at the affected levels. Therefore, the request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
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 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. 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. The enrollee was admitted for surgical treatment of a hip
fracture after a fall and non-surgical management of thoracic compression fractures. Medical problems are
stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.

You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the request for Prolia is not necessary based on the
enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the
request for Prolia is not medically reasonable and necessary. Our physician reviewer found the enrollee was
evaluated for osteopenia. A reported t-score is consistent with osteopenia, not osteoporosis. There is no
evidence that the enrollee has taken other osteoporosis medications and been unresponsive to them or intolerant
of them.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia 60 mg/ml syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary to control the enrollee's 
anemia. The Plan denied your request. The Plan says the enrollee does not have a covered condition. 
 
The Plan follows Medicare rules. Medicare rules say that (ESA) treatment for the anemia secondary to 
myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic 
leukemia is only reasonable and necessary under the specified conditions in the LCD. 
 
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 Aranesp. Our reviewer says that the 
criteria for coverage of Aranesp have not been met. Our physician reviewer found Aransep is FDA-approved 
for the treatment of anemia in patients with nonmyeloid malignancies when anemia is due to the effect of 
concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of 2 additional months 
of planned chemotherapy. Given he started carboplatin/alimta in November, it would be expected for him to be 
close to completion. In addition, there are no iron studies or B12 to rule other concomitant causes.  There is no 
off-label support or support from the literature. The service is not reasonable or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction provided to the enrollee.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not covered out-of-network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in-network provider.

We looked at the file and the Plan's rules. The refraction was provided by an out-of-network provider. The Plan only covers eye refractions from in-network providers. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone, Fosaprepitant IV, Palonosetron and Fulphila.

You asked the Plan to pre-approve Dexamethasone, Fosaprepitant IV, Palonosetron and Fulphila. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Dexamethasone, Fosaprepitant IV, Palonosetron and Fulphila. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has pancreas cancer. The requested drugs are not indicated for low emetogenic potential chemotherapies like abraxane and gemcitabine. The requested use of the drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drugs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dexamethasone, Fosaprepitant IV, Palonosetron and Fulphila have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone, Fosaprepitant IV, Palonosetron and Fulphila.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia services (D9222, D9223).

You asked the Plan to pre-approve general anesthesia services. You say that this service is medically necessary.
The Plan denied your request. The Plan says the provider does not have the necessary permits to perform this
type of service.

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. The Plan covers general
anesthesia services when the services are medically necessary and reasonable.

We looked at this physician's review, the file, and Medicare rules. The case file indicates that the dentist is not
licensed to perform the selected anesthesia services. Based on this information, we decided that the Plan's rules
for coverage of general anesthesia services have not been met. Therefore, we decided that the Plan does not
have to pre-approve general anesthesia services (D9222, D9223).
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 this is medically necessary due to the enrollee's respiratory issues. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current facility.

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 patient is currently undergoing treatment at an acute care hospital (ACH) for complications following recent femoral bypass surgery. The enrollee is receiving wound care and antibiotics. 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 long term care needs.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services to be provided in the home
and home health aide services.

You asked the Plan to pre-approve the home physical therapy and home health aide services. You say that you
do not need to be a Medicare certified home health agency to provide the services at issue. You are a doctor's
office billing for services provided in the home, and these services should be covered. The Plan denied your
request. The Plan says home health services must be provided by a Medicare certified HHA.

The Plan must follow Medicare rules. Medicare rules say that home health services are covered when provided
by a home health agency that has a Medicare provider agreement.

The services being requested are considered home health services. As such, they are not covered when
provided and billed by a doctor's office. Therefore, we decided that the Plan does not have to pre-approve the
physical therapy services to be provided in the home and home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional
improvement however, the documentation does not support that you would meet criteria for admission to an
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits
weekly to regain or maintain his functional status. You are ambulating up to 15 feet with minimal assistance.
You are near your prior level of function and could receive services 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
You asked the Plan to pre-approve this item. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollee with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
this item have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 
14 day/sensor/flash monitoring system for the enrollee.  
 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 day/sensor/flash monitoring system 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
You asked the Plan to pay for the billed services. You say that these were billed correctly and should be paid. 
The Plan denied your request. The Plan says there were billing errors on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The 
rules also say that the inpatient POS code must be used.  
 
In this case, the enrollee was an inpatient at the time of service. As the TC of the services are not considered 
physician services, they are included in payment to the facility and are not separately payable. In addition, the 
POS code 15 is not appropriate for services provided to an inpatient. Therefore, we decided that the Plan does 
not have to pay for the technical components (TCs) of the neuromuscular junction (NMJ) testing and 
electromyography (EMG) testing provided on May 21, 2020 coded as 95937-TC-59 and 95861-TC-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of monitored anesthesia care (MAC) during an 
injection. 
 
You asked the Plan to pre-approve the services. You say that  The Plan denied your request. The Plan says 
monitored anesthesia care is rarely needed in this case. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no indication for monitored anesthesia care. There are no unstable medical conditions, 
obstructive sleep apnea, or morbid obesity. The request is not 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of monitored anesthesia care (MAC) during an injection.
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 services are 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. 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered soon. 

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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require inpatient hospital services and does not 
require daily skilled therapies. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.