Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton therapy.  You asked the Plan to pre-approve the proton therapy. You say that you would like reconsideration because this therapy is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested therapy.  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 proton therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found both ASTRO and the NCCN guidelines recommend against routine use of proton therapy. Proton Therapy would arguably exceed the member's needs and it is unknown if this would be more effective than the standard 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 the proton therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. 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 ventilators (E0465, E0466, and E0467) 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 a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation to suggest any positive airway pressure (PAP) device including a bilevel positive airway pressure (BiPAP) with back up rate and average volume assured pressure support (AVAPS) was utilized. 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 a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA).  You asked the Plan to pre-approve thermal facet joint RFA. You say that the services are not medically 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 an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients that meet specific criteria.  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 thermal facet joint RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the criteria of the LCD to approve RFA is for 2 separate sets of diagnostic medial branch block (MBBs), both of which provide over 80% pain relief. This enrollee has had only one set. Further, fluoroscopy is an integral part of the diagnostic and therapeutic procedure, therefore it is not unbundled and billed separately. The request for the RFA is not medically reasonable or necessary at this point.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thermal facet joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a wired basket for a walker.  You asked the Plan to pre-approve the basket. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily used for a medical purpose.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wired basket for a walker.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional sixty-two (62) miles for routine transportation (A0120).  You asked the Plan to pre-approve an additional 62 miles for routine transportation. You say that you need the additional mileage for transportation to see your neurologists and you are not able to drive. The Plan denied your request. The Plan says you have exceeded your benefit limit.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation for 48 one-way trips per calendar year to Plan-approved locations. Each one-way trip must not exceed 50 miles of driving distance.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve an additional sixty-two (62) miles for routine transportation (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7230).  You asked the Plan to pre-approve removal of an impacted tooth. You say that the enrollee has an infection, cellulitis, partial bony tooth, swelling and severe pain and cannot use her teeth or bite down. You also say that it is medically necessary to have this procedure done for the enrollee's health. The Plan denied your request. The Plan says the service is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of an impacted tooth (D7230).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the upper spinal canal.  You asked the Plan to pre-approve an MRI scan of the upper spinal canal. 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 scan of the upper spinal canal. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria 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 an MRI scan of the upper spinal canal have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the upper spinal canal.
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 additional help. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.  The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 SNF admission. You say that it is felt that SNF care is medically necessary. The Plan denied your request. The Plan says daily skilled services are not required.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital, the member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital.  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 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 2, 2021.  You asked the Plan to pre-approve the continued SNF care. You say that you feel that you are not ready to be discharged from the SNF. The Plan denied your request. The Plan says you no longer require daily skilled services.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on 11/15/2021 after a hospital stay for a mechanical fall. The most recent therapy documentation indicates the member is able to ambulate household distances with a walker. He does not require hands on assistance. As of 12/2/2021, the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 12/2/2021.  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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 2, 2021.
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 you do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services. The Plan denied your request. The Plan says skilled nursing facility services  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical record is reviewed in its entirety.  The member has stabilized medically and is ready for discharge you do not have any parental medication; complex wound care or nutrition given via a feeding tube.  You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near his baseline. Medicare coverage criteria for this admission are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical record shows you are stabilized medically and ready for discharge from the hospital. The records do not show that you require skilled nursing and/or skilled therapy services daily.  You do not have any parental medication or complex wound care, or nutrition given via a feeding tube.  You are medically stable without any acute exacerbations of chronic medical problems. You are unable to participate with skilled, daily therapy due to pain and movement restrictions due to the fracture.  Medicare criteria for skilled nursing facility services are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility 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 SNF admission. You say that it is felt that SNF admission is required at this time. The Plan denied your request. The Plan says SNF admission is not currently medically reasonable and 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 the SNF admission. Our reviewer says that discharge to a SNF is not medically appropriate at this time. Our physician reviewer found the enrollee was recently admitted to the hospital due to hemorrhagic stroke. She was diagnosed with an intracranial bleed and required multiple craniectomies and had a subsequent brain abscess. She has been in a vegetative state since the stroke and is dependent on a ventilator and feeding tube. It was a complicated hospital stay and when she stabilized, she was discharged to a long-term acute care hospital (LTACH). She has been treated for pneumonia and has been treated for increased secretions.  The member is not currently stable for transfer to a lower level of care. She continues to require skilled nursing services and complex medical care that can be provided at the current LTACH. The member's is not able to work meaningfully with skilled therapy due to baseline cognitive impairments. There are no services offered at a skilled nursing facility that are not offered at a LTACH. Admission to a SNF for inpatient skilled services is 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 the SNF 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve invasive vascular imaging, to include selective catheter placement, venography, and intravascular ultrasound (IVUS).  You asked the Plan to pre-approve the requested invasive vascular imaging. You say that the enrollee requires these procedures to investigate the cause of her vascular issues. The Plan denied your request. The Plan says this is not a medically necessary course of treatment at this time.  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 requested invasive vascular imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of varicose veins with pain/swelling/cramping/restlessness in the right leg for 3 years. The patient's physician suspects May-Thurmer syndrome (MTS) and has requested invasive imaging for her management. The patient has not exhibited acute symptoms such as blood clots, nor has there been pain or swelling of the entire limb.   An exhaustive review of the literature reveals that for suspected MTS, non-invasive imaging studies should be obtained first. In the absence of conclusive clinical studies, guidelines have not yet endorsed the use of invasive imaging, such as IVUS, for this role. At the current time, it is not felt that the requested procedures are medically necessary for this patient.  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 requested invasive vascular imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve invasive vascular imaging, to include selective catheter placement, venography, and intravascular ultrasound (IVUS).