Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The Plan denied your request. The Plan says the requested Orthovisc 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 Orthovisc. Our reviewer says that the requested Orthovisc is not medically necessary. Our physician reviewer found the enrollee has complete medial compartment joint space collapse with developing varus deformity. Criteria for Orthovisc have not been met. More conservative measures are needed for knee pain such as physical therapy and a trial of a knee steroid injection.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for RST neoGen-Series (Sanexas Treatment) combined with subcutaneous Nutri-Pharmaceutical injections provided on December 29, 2020.

You asked the Plan to pay for RST neoGen-Series (Sanexas Treatment) combined with subcutaneous Nutri-Pharmaceutical injections: Injection, levocarnitine, per 1 gm  (J1955), Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Drugs unclassified injection (J3490). You say that the Plan should pay this claim.The Plan denied your request. The Plan says experimental or investigational services are not covered.

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 pay for RST neoGen-Series (Sanexas Treatment) combined with subcutaneous Nutri-Pharmaceutical injections: Injection, levocarnitine, per 1 gm  (J1955), Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Drugs unclassified injection (J3490). Our reviewer says that the procedure was not medically reasonable or necessary. Our physician reviewer found this is an experimental/ investigational therapy. 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 RST neoGen-Series (Sanexas Treatment) combined with subcutaneous Nutri-Pharmaceutical Injections: Injection, levocarnitine, per 1 gm  (J1955), Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Drugs unclassified injection (J3490) have not been met.Therefore, we decided that the Plan does not have to pay forRST neoGen-Series (Sanexas Treatment) combined with subcutaneous Nutri-Pharmaceutical injections provided on December 29, 2020.
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 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 dizziness and gastrointestinal bleeding. Medical conditions 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, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation
program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for a continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees 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 insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to pre-approve a Fluid Flow stem cell injection.

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 services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that stem cell therapy is covered when specific 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 these services. Our reviewer says that the enrollee does not have a condition for which stem cell therapy is covered. Our physician reviewer found the enrollee has low back pain. She does not have a condition for which stem cell therapy is covered by the Medicare criteria. The use of Fluid Flow for back pain has not been demonstrated to be a standard of care as is therefore still considered experimental and investigational and not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Fluid Flow stem cell injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (POV).

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 services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a POV is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the enrollee has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related activities of daily living (MRADLs); however, he weighs 274 pounds. The records do not support that the enrollee's weight is appropriate for the requested Group 1 heavy duty POV; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle (POV).
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 24, 2021 and underwent kyphoplasty on May 26, 2021 and anterior cervical discectomy and fusion on May 28, 2021.

The most recent therapy notes state he needs varied assistance for balance while washing hands at the sink, toileting, clothing management, and pericare. He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has normocytic anemia and stage 3b chronic renal insufficiency. She has not tried and failed the Plan's required drug, Retacrit. The records do not show that the required drug would be contraindicated or less effective; therefore, Aranesp 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
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 the enrollee lives alone and is not able to return home at this time. The Plan denied your request. The Plan says SNF care is not medically necessary. The Plan says that the enrollee's needs can be met in the current acute care setting.

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 necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy in the acute hospital. The enrollee was at a modified independent to stand by assist level with functional mobility, including gait to 60 feet with a rolling walker. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (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 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 the enrollee as admitted to the hospital on April 24, 2021 with a distal femur fracture and underwent surgical repair. He received oral medications and had stable vital signs. He received physical and occupational therapy and needs assistance with gait to 150 feet and activities of daily living. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided by a licensed professional counselor.

You asked the Plan to pre-approve the requested services. You say that you have built a complex relationship with this provider. The Plan denied your request. The Plan says the requested services are not covered by the Plan.

The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is not eligible to participate in Medicare.

We looked at the file and Medicare rules. A licensed professional counselor is not eligible to participate in Medicare. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided by a licensed professional counselor.
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 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 repair of a hip fracture and non-surgical management of a wrist fracture after a fall. Medical conditions 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, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there
is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.

You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical justification for the non-preferred brand.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

There are no medical records provided for this case. Without clinical records, it cannot be proven that there is a specific medical need for this brand of test strips. Based on this information, we decided that Medicare rules for coverage of the test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.

You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the enrollee needs hyperbaric oxygen therapy for sudden hearing loss. The Plan denied your request. The Plan says hyperbaric oxygen therapy is not covered for the enrollee's diagnosis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The enrollee's diagnosis is not listed as a covered diagnosis for hyperbaric oxygen therapy. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested PCD.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).