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

 We decided that the Plan does not have to pre-approve Rituxan.  You asked the Plan to pre-approve Rituxan. You say that the requested Rituxan is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Truxima or Ruxience first.  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 Rituxan. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the Plan's required drug(s) 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).  You asked the Plan to pre-approve Orthovisc. You say that, since the enrollee is unable to receive cortisone injections in between each series of viscosupplementation injections, you are asking the Plan to make an exception and approve the requested treatment before the 6-month waiting period. The Plan denied your request. The Plan says rules for coverage for the requested treatment have not been met.  The Plan must follow Medicare rules. The rules say that a repeat series of injections may be allowed when the criteria listed in the Medicare rules section have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Specifically, the provided medical records document that the enrollee's last injection in a prior course was given fewer than six months ago. There is no provision for an exception to the rules. Therefore, we decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast.  You asked the Plan to pre-approve an MRI of the breast. 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. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the breast. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review of the records showed no results of prior mammograms. This is important in order to assess the density of breast tissue on mammography. If this enrollee has heterogenously or extremely dense tissue on mammography the need for screening with an MRI would be elevated due to the limitations of mammography in the presence of dense tissue. Invasive lobular cancer can be difficult to detect with mammography and the records indicate her original tumor was mammographically occult. Without knowledge of her breast density the medical necessity of breast MRI cannot be assessed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the breast have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Hylan.  You asked the Plan to pre-approve Hylan. You say that you tried cortisone injections, but they did not relieve your pain. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because there is no clinical indication for Hylan.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Hylan. Our reviewer says that you do not meet the criteria for the requested use of Hylan. Our physician reviewer found Hylan is not Food & Drug Administration (FDA) approved for your condition. The record does not show that you have not responded to conservative non-drug therapy or simple analgesics such as acetaminophen. The requested use of Hylan is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hylan have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Hylan.
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 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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Paraguard intrauterine device (IUD).  You asked the Plan to pre-approve Paraguard IUD. 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 items/services for the purposes of preventing conception (contraception) are not considered medically reasonable and necessary.   Records show that the requested service is primarily for the purpose of contraception. The documentation does not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pre-approve Paraguard intrauterine device (IUD).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve heart catheterization and ventriculography.  You asked the Plan to pre-approve heart catheterization and ventriculography. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 heart catheterization and ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation to support the medical necessity of cardiac catheterization with left ventriculography in your clinical management.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of heart catheterization and ventriculography have not been met. Therefore, we decided that the Plan does not have to pre-approve heart catheterization and ventriculography.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that you were not pleased with previous network providers. The Plan denied your request. The Plan says appointments are available with in-network providers.  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. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services billed with secondary diagnosis code I50.43, (Acute on chronic combined systolic [congestive] and diastolic [congestive] heart failure) provided from January 19, 2021 to February 1, 2021.  You asked the Plan to pay for the inpatient services billed with secondary diagnosis code I50.43. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code I50.43 identified as (Acute on chronic combined systolic [congestive] and diastolic [congestive] heart failure). 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 the inpatient services billed with secondary diagnosis code I50.43. Our reviewer says that the documentation does not support the secondary diagnosis billed. Our physician reviewer found the enrollee chronic ulcer of the foot with necrosis of bone, type 2 diabetes mellitus who was treated with amputation in the inpatient hospital was billed with secondary diagnosis code I50.43, (Acute on chronic combined systolic [congestive] and diastolic [congestive] heart failure). Vitals were normal with no hypoxia, physical examination findings did not show any respiratory distress or work of breathing, and there was no notable edema suggestive of acute on chronic congestive heart failure to justify the above secondary diagnosis. Therefore, there was insufficient support made in the provided documentation for secondary diagnosis code I50.43.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services billed with secondary diagnosis code I50.43, (Acute on chronic combined systolic [congestive] and diastolic [congestive] heart failure) provided from January 19, 2021 to February 1, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve an epidural steroid injection.  You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are 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 an epidural steroid injection. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has had a series of epidural steroid injections which have provided substantial relief. The request is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient admission beyond 90 acute care days.  You asked the Plan to pre-approve inpatient admission beyond 90 acute care days. You say that the services are necessary. The Plan denied your request. The Plan says the 90-day benefit has been exhausted. You have the option to utilize the 60 lifetime reserve days you have remaining.  The Plan must follow Medicare rules. Medicare rules say that each beneficiary has a lifetime reserve of 60 days of inpatient hospital services to draw upon after having used 90 days of inpatient hospital services in a benefit period.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission beyond 90 acute care days have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission beyond 90 acute care days.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260).  You asked the Plan to pre-approve a CT scan. You say that this was recommended by the radiologist. The Plan denied your request. The Plan says this is not necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the paratracheal lymph nodes were described as lessening in size since January 10, 2019.  There is no recommendation in the report for continued surveillance.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.  You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 insertion of a subcutaneous cardiac rhythm monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation to support the medical necessity for insertion of an implantable cardiac monitor in this enrollee's clinical management.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a subcutaneous cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor.
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 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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.  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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found bon the medical records provided, there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 24, 2022, forward.

You asked the Plan to pre-approve inpatient psychiatric care from January 24, 2022, forward. You say that the
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are
not medically necessary.

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 inpatient psychiatric care from January
24, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental
health treatment beyond the date in question of January 24, 2022, forward. Our physician reviewer found the
enrollee did not require inpatient mental health treatment beyond January 24, 2022, as he was not a danger to
himself or others and did not have any delusions, auditory or visual hallucinations. 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 the enrollee's condition or for the
purpose of diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from January 24, 2022, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 24,
2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synthroid 50mcg tablets.  You asked the Plan to pre-approve Synthroid. You say that Synthroid is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Synthroid 50mcg tablets.   Benefits for Synthroid may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.