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

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that the enrollee is a good
candidate for this procedure. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.
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 insertion of a Vertiflex device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF admission 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 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 review has determined that the complexity of the 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. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF. 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 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis.
You asked the Plan to pre-approve Lucentis. 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.
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 Lucentis. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records did not show that the enrollee had tried and failed bevacizumab for her macular degeneration. There were no reported contraindications or factors described by the prescribing physician that the required bevacizumab would likely be less effective or lead to more side effects than the requested Lucentis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines, the SNF services you and/or your provider are requesting do not meet the requirements for approval regarding SNF admission from home.
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 the SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, you received oral medications. You had stable vital signs. You were treated for pain with effect.
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the
acute hospital. You were at a contact guard assist level with functional mobility including gait to 125 feet with
a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled
nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing
or therapy services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. You say that you have been episodes of falling. The Plan denied your request. The Plan says you do not have wound care needs and can have intermittent therapy.
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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist to contact guard assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF is necessary to control all of your conditions
and provide intensive therapy to return you to baseline. You feel that a skilled nursing facility (SNF) would not
provide the therapy you require. The Plan denied your request. The Plan says rules for IRF care have not been
met because the requested level of care 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 that the documentation does not support that the complexity of your nursing,
medical, and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. The documentation does not support that you require at least 3 hours a day/5 days a week,
or 15 hours over 7 consecutive days, of therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission for the
enrollee.
You asked the Plan to pre-approve SNF admission. You say that SNF admission 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 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
setting. Medicare coverage criteria are not met. 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-approve skilled nursing facility (SNF) admission
for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01170)
You asked the Plan to pay for anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says the records do not include an anesthesia report.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 01170 is anesthesia for open procedures involving symphysis pubis or sacroiliac joint. We find that CPT code 01170 is not supported in the medical record. Specifically, the submitted documentation does not include an anesthesia record. Without this information, this code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore,
we decided that the Plan does not have to pay for anesthesia services (01170)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on July 8, 2021 with a hematoma after receiving a Lupron shot. You are now consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. You do not have skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery for the enrollee.
You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria or this surgery. 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 this surgery. Our reviewer says the enrollee does not
meet the required LCD criteria for failure to document participation in a structured dietary program. The
patient has failed to maintain a healthy weight despite adequate participation in a structured dietary program
overseen by one of the following: Physician (MD or DO), Registered dietician (RD), Board certified specialist
in pediatric nutrition (CSP), Board certified specialist in renal nutrition (CSR) or Fellow of the American
Dietetic Association (FADA). We looked at this physician's review, the file, and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of this surgery have not been met. Therefore, we
decided that the Plan does not have to pre-approve bariatric surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair seat cushion (E2622).
You asked the Plan to pre-approve a wheelchair seat cushion. You say that you are disabled, and your buttocks
gets sore because you have no fat on your buttocks. The Plan denied your request. The Plan says the enrollee
does not meet the Medicare criteria for the requested seat cushion.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The records did not show that that the enrollee has either a manual or powered wheelchair. We looked at the
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a
wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a
wheelchair seat cushion (E2622).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Haemophilus influenzae type b vaccine you received on
February 8, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered
under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the Haemophilus influenzae type b vaccine you
received on February 8, 2021.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says 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 patient requires that are not already available and covered at the current facility. 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 services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network skilled nursing facility services. You say that the skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says there are in-network skilled nursing facilities available. The services at issue are not emergent. The out-of-network provider has not been approved.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve skilled
nursing facility services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee is no longer qualified for inpatient rehabilitation and no longer needs intensive care. You state the enrollee is improving with therapy but is needing additional therapy care with SNF. 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 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 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 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 pre-approve SNF care, for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on April 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility services.
You asked the Plan to pre-approve the Skilled Nursing Facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 the Skilled Nursing Facility services.
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the
documentation does not support that skilled services are required on a daily basis in a SNF on an inpatient
basis.
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 Skilled Nursing Facility services have not been met. Therefore, we decided
that the Plan does not have to pre-approve Skilled Nursing Facility services