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

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300), a wheelchair
controller (E2311), expandable controller (E2377), harness (E2313), and transfer handles (K0108).
You asked the Plan to pre-approve the power wheelchair features. You say that the features should be covered.
The Plan denied your request. The Plan says these services are not covered.
The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) is non-covered
because they are not primarily medical in nature. The rules also say that if an attendant control (E2331) is
provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.
The electrical connection between the wheelchair controller and two or more motors (E2311), expandable
controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options
on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power
options through the joystick.
Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature (E2300), a
wheelchair controller (E2311), expandable controller (E2377), harness (E2313), and transfer handles (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab (Prolia).
You asked the Plan to pre-approve Prolia. You say that the enrollee has a diagnosis of Osteoporosis. You also say that the enrollee has taken and is unable to tolerate Alendronate (Fosamax) due to a gastrointestinal intolerance. The Plan denied your request. The Plan says this request does not meet step therapy requirement for the requested medication. dicare 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 Prolia. Our reviewer says that Prolia is not medically reasonable or necessary for the enrollee. Our physician reviewer found the Plan requires a trial of intravenous bisphosphonate before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (Prolia).
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH have not been met. The enrollee's medical needs are being met in the current acute care setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 record indicates that the enrollee remains critically ill with ventilator dependence. The enrollee is receiving acute care services at the current facility, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair.
You asked the Plan to pre-approve a shower/bath chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a shower/bath stool is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower/bath chair may be appropriate 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 shower/bath chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 5, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you are still in need of inpatient psychiatric care and are a danger to yourself and others. The Plan denied your request. The Plan says the criteria for acute psychiatric care at an inpatient level are no longer met. You can be treated in a less restrictive setting as you are currently stable and no longer an imminent threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued inpatient psychiatric services appears appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on October 21, 2021 with Major Neurocognitive Disorder Unspecified with Behavioral Disturbance. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and were without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 5, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 5, 2021, onward.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 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. There is no need for physical medicine and rehab physician supervision 3 times per week for the ongoing
management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. Based upon your current level of function it is not clear how much you can tolerate the IRF level of therapies and do not require an intensive, complex, multidisciplinary approach to daily therapy. You need physical and occupational therapy in an alternate low intensity level. Additionally, you will not make significant functional recovery in the predicted 14 days of IRF care. You do not need a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. You will do just as well with skilled nursing facility therapies. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 diagnostic mammography to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a diagnostic mammography to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a diagnostic mammography 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 skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. 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 a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration
because this procedure is medically necessary. The Plan denied your request. The Plan says the member does
not meet coverage criteria for the requested service.
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 Vertiflex Superion Spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the record indicates that an assessment for osteoporosis was requested but
the results are not provided.
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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnesium sulfate, cisplatin, pemetrexed, and durvalumab.
You asked the Plan to pre-approve the magnesium sulfate, cisplatin, pemetrexed, and durvalumab. You say that you would like reconsideration because these drugs are medically necessary. 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 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 magnesium sulfate, cisplatin, pemetrexed, and durvalumab. Our reviewer says that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee has a diagnosis of adenocarcinoma of the lung (non-small cell lung cancer). The requested regimen is consolidation with durvalumab following pemetrexed and cisplatin. The record indicates that the enrollee has only received one cycle of cisplatin and pemetrexed and no assessment of disease progression after two cycles has been performed. 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 magnesium sulfate, cisplatin, pemetrexed, and durvalumab have not been met. Therefore, we decided that the Plan does not have to pre-approve magnesium sulfate, cisplatin, pemetrexed, and durvalumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary 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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's last RFA was performed July 11, 2019. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a trial of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that it is felt that this treatment would be the best 
option for the enrollee's pain. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cords stimulators are considered medically 
necessary for treatment of intractable chronic pain when the other criteria listed in the Medicare rules section 
are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SCS trial. Our reviewer says that 
the documentation does not support the medical necessity of this SCS at this time. Our physician reviewer found the record indicates that the enrollee has chromic leg and back pain, myofascial pain, and peripheral 
neuropathy. The provided record does not indicate that the enrollee has intractable pain, and that 
pharmacologic therapy and trigger point injections are helpful. The record does not indicate that the enrollee 
has failed physical therapy. The elements of the coverage criteria are not satisfied. 
 
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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a trial of a spinal cord stimulator (SCS).
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 the IRF care. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines for coverage.
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 the 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of facet joint nerves.
You asked the Plan to pre-approve the facet joint RFA procedure. You say that it is felt that this is needed. The
Plan denied your request. The Plan says it appears the incorrect procedure was requested. The Requested
procedure is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that RFA of facet joints are covered when prior facet joint
injections produced 80% or greater relief.
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 facet joint RFA procedure. Our
reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the record
indicates that the enrollee has had two sacroiliac joint injections in 2019 and 2020, each providing 50% relief.
There were no facet joint injections as required per the LCD. It appears that the incorrect code was requested as
the records show a plan for sacroiliac rhizotomy, which is not the procedure requested/denied. The procedure
requested does not meet criteria.
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 facet joint RFA procedure have not been met. Therefore, we decided that the
Plan does not have to pre-approve radiofrequency ablation (RFA) of facet joint nerves.