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

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 respiratory failure, coronavirus (COVID-19) pneumonia, Klebsiella pneumonia, and critical limb ischemia for which embolectomy was performed. 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, and 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. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve your over-the-counter (OTC) benefits for each quarter to be used before the end of the 2021 plan year.  You asked the Plan to pre-approve the OTC benefits. You say that in January 2021 you were advised by a Plan associate that you did not have OTC benefits. You also say that you did not find out until October 30, 2021 that you had OTC benefits of $25 per quarter and you believe you should be allowed to use each quarter's benefit before the end of 2021. The Plan denied your request. The Plan says any unused quarterly benefit is forfeited at the end of each quarter.  The Plan must follow Medicare rules. The Plan offers a $25 OTC allowance per quarter which cannot be carried over to another quarter if it is unused. Therefore, we decided that the Plan does not have to pre-approve your over-the-counter (OTC) benefits for each quarter to be used before the end of the 2021 plan year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit and supplies.  You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says the required clinical data was not received.  The Plan must follow Medicare rules. Medicare rules say that in order to cover a TENS unit, there must be supporting medical records.      Despite multiple attempts by the plan, records were not received for this request. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) unit and supplies.
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 you need LTACH care due to being on a ventilator and still having a feeding tube. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 available at the LATCH that you require that are not available at the health care setting being offered by the Plan.  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 foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the orthotics will compensate for the unevenness of your feet and allow you balance for walking. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 need inpatient rehabilitation services and will benefit from three hours per day of therapy services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve ablation (64624).  You asked the Plan to pre-approve genicular nerve ablation. You say that this is medically necessary. 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 genicular nerve ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation (64624).
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 requested admission to an IRF does not meet criteria.  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 your current medical condition does not require intensive physician or nursing supervision in an IRF. You are non-weight bearing and limited by fatigue. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF or will be fully tolerated on an intensive level 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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 19, 2021.  You asked the Plan to pay for to pay for. You say that this was medically necessary. The Plan denied your request. The Plan says the ordering of numerous infectious agent detection tests are not supported for common urinary tract infection (UTI) concerns.  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 pay for to pay for. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient diagnosis and service information to support the obtained tests. There was no specific clinical rationale for the obtained tests. The review has determined that the services at issue in this case were 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 to pay for have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Abraxane.  You asked the Plan to pre-approve Abraxane. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested drug would be deemed a routine cost covered by the Medicare Administrative Contractor.  The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.  In this case, you asked the Plan to pre-approve Abraxane as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Abraxane.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Xifaxan tablet.  You asked the Plan to pre-approve Xifaxan. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.    The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xifaxan tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).  You asked the Plan to pre-approve a power operated vehicle. You say that the item at issue is a medical necessity for you. The Plan denied your request. The Plan says rules for a power mobility device have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Fluid Flow (amniotic fluid) injection of both knees.  You asked the Plan to pre-approve the Fluid Flow (amniotic fluid) injection of both knees. You say that you would like reconsideration because the enrollee's way of living is being affected and the injection is needed to correct his situation. The Plan denied your request. The Plan says Fluid Flow is considered investigational and not medically necessary for the treatment of chronic knee pain/osteoarthritis of the knee.  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 Fluid Flow (amniotic fluid) injection of both knees. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been shown to be safe and effective in long term studies. Joint injection of human amniotic fluid is considered experimental, investigation, and or unproven for all indications, including the treatment of osteoarthritis.   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 Fluid Flow (amniotic fluid) injection of both knees have not been met. Therefore, we decided that the Plan does not have to pre-approve the Fluid Flow (amniotic fluid) injection of both knees.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (27381, 27487) provided July 14, 2021.  You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 27381, & 27487 are not supported in the medical record. Specifically, the operative report does not describe a suture of an infrapatellar tendon or a total knee revision. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27381, 27487) provided July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a raised toilet seat.  You asked the Plan to pre-approve a raised toilet seat. You say that you cannot get up off the regular toilet and you need the raised seat to help getting up. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.   While a raised toilet seat may be appropriate for S. Peer, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nine office visits to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.  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 nine office visits to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a peripheral arterial examination, lower extremity.  You asked the Plan to pre-approve a peripheral arterial examination, lower extremity. The Plan denied your request. The Plan says a peripheral arterial examination, lower extremity is 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 a peripheral arterial examination, lower extremity. Our reviewer says that the requested peripheral arterial examination, lower extremity is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 74-year-old male who had surgical correction of hallux deformity and hammering deformities of toes without complication. The provided documentation did not clearly reveal an abnormal physical examination or ankle brachial index (ABI) to support following up with more advanced testing to screen for peripheral arterial examination. Therefore, based on the provided documentation, the peripheral arterial examination, lower extremity will be considered 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 a peripheral arterial examination, lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral arterial examination, lower extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve the concentrator. You say that this is needed for traveling and in case of power outages. The Plan denied your request. The Plan says this is being requested for travel and use outside of the home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer (J1439).  You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have 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 Injectafer. Our reviewer says that the requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a trial of Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. The patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).