Persius/hicric huggingface dataset:
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 enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 syncope, bradycardia, and hypotension. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the
enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered for treatment of lymphedema of the extremities alone.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee chronic venous hypertension and lower extremity lymphedema that
does not extend to the abdomen, chest, or trunk. 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic 4mg/3ml injections.
You asked the Plan to pre-approve Ozempic. You say that Ozempic is medically necessary. The Plan denied your request. The Plan says this drug is for self-administration and 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 Ozempic 4mg/3ml injections.
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
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 the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 based on the documentation provided the enrollee appears to not be stable enough for
transfer at this time. Acute care services can be safely administered at the current facility for the time being
until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not
require services at the LTACH that are not already available at the current facility. There are no services at the
LTACH that the enrollee requires that are not already available and covered at the current 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 3, 2020, through November 30, 2020 and billed with Patient Driven Payment Model (PDPM) score KDKE1 x 28 days.
You asked the Plan to pay for the SNF services billed with PDPM score KDKE1 x 28 days. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says the documentation submitted does not support the PDPM score billed
The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM score KDKE1 x 28 days have not been met. Specifically, the documentation submitted is incomplete. There is no ICD Code entered at Minimum Data Set (MDS) Section I0020B, no Admission Performance of the Self Care and Mobility activities entered at MDS Sections GG0130 and GG0170 and the assessment did not generate a HIPPS code for billing. Without this information we are unable to validate the billed PDPM score. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 3, 2020, through November 30, 2020 and billed with Patient Driven Payment Model (PDPM) score KDKE1 x 28 days.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Triluron (J7332).
You asked the Plan to pre-approve the Triluron. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.
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 the Triluron. Our reviewer says that Triluron (J7332) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Orthovisc OR Supartz FX. Our reviewer also found that 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. 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 Triluron have not been met. Therefore, we decided that the Plan does not have to pre-approve Triluron (J7332).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of facet nerves (64636, 64635).
You asked the Plan to pre-approve radiofrequency ablation of facet nerves. You say that the service is
medically necessary. The Plan denied your request. The Plan says the service 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 radiofrequency ablation of facet nerves.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found documentation shows that you only had one set of diagnostic blocks
and only achieved 75% pain relief.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation of facet nerves have not been met. Therefore, we
decided that the Plan does not have to pre-approve radiofrequency ablation of facet nerves (64636, 64635).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is medically
necessary. The Plan denied your request. The Plan says the requested service is considered experimental and
investigational. The Plan says that the requested procedure is not identified as widely used and generally
accepted for the proposed use.
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 an Intracept procedure. Our reviewer
says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy of the procedure.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and
interpretation with field of view of both jaws; with or without cranium (D0367), bone replacement graft for
ridge preservation - per site (D7953), and guided tissue regeneration - resorbable barrier, per site (D4266)
provided June 28, 2021.
You asked the Plan to pay for the cone beam CT scan, bone replacement graft and guided tissue regeneration.
You say that you don't understand why the services were not covered. The Plan denied your request. The Plan
says these services are not covered under your benefits.
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 pay for the cone
beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without
cranium (D0367), bone replacement graft for ridge preservation - per site (D7953), and guided tissue
regeneration - resorbable barrier, per site (D4266) provided June 28, 2021.
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 admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically
and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled
therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level
of care. Although further rehab 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. The member
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or
near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled
rehab 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 admission to a SNF 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 February 1, 2022, forward.
You asked the Plan to pre-approve inpatient psychiatric care from February 1, 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 February 1, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 1, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 1, 2022, as you were not a danger to yourself 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 your 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 February 1, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 1, 2022, forward.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve a Greater Occipital nerve block.
You asked the Plan to pre-approve a Greater Occipital nerve block. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 Greater Occipital nerve block. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found imaging shows degenerative changes at C2 along with edema. Greater Occipital nerve block is standard of care for the diagnosis of occipital neuralgia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Greater Occipital nerve block have been met. Therefore, we decided that the Plan has to pre-approve a Greater Occipital nerve block.
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 that the enrollee continues to receive acute care services, and these have not been
denied. The medical record does not indicate that the enrollee requires services that he is not currently
receiving but that would be available at the LTACH 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device.
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that the CardioMEMS
implant is medically reasonable and necessary. The Plan denied your request. The Plan says the requested
service is not considered 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 the insertion of a CardioMEMS device.
Our reviewer says that the insertion of a CardioMEMS device is not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has chronic heart failure (CHF) with mild-
moderately reduced left ventricular function. The CardioMEMS device was approved by the Food and Drug
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow
measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients
in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection
fraction and was somewhat limited in scope.
Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with
the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management.
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary
in this patient'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 the insertion of a CardioMEMS device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device.