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

 We decided that the Plan does not have to pre-approve repeat breast reduction for the enrollee.  You asked the Plan to pre-approve repeat breast reduction for the enrollee. You say that due to menopause, the enrollees' breasts have enlarged to the point they are creating repeat symptoms of midscapular back pain, bra stray grooving with neck and shoulder pain. The Plan denied your request. The Plan says repeat reduction mammoplasty is not considered medically necessary unless there are complications resulting from the first surgery of which there is no documentation submitted.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. Insufficient medical records were submitted to justify coverage of repeat surgery. Therefore, we decided that the Plan does not have to pre-approve repeat breast reduction for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this service should not be unbundled.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says you do not require daily skilled care that can only be provided in a facility.
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. You are not shown to have an acute decline in function. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs appear to be custodial and, as a practical matter, can be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azelastine.
You asked the Plan to pre-approve Azelastine. The Plan denied your request. The Plan says this is not a 
covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Azelastine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network provider.
You asked the Plan to pre-approve the continuation of care with an out-of-network provider. You say that the requested continuation of care with an out-of-network provider is medically necessary. The Plan denied your request. The Plan says the requested continuation of care with an out-of-network provider is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continuation of care with an out-of-network provider. Our reviewer says that the requested continuation of care with an out-of-network provider is not medically necessary. Our physician reviewer found the record indicates that the enrollee has diagnoses of peripheral ulcerative keratitis of both eyes, corneal neovascularization of left eye, corneal scarring and corneal perforation of right eye. The record indicates that the enrollee last had a visit with an out of network optometrist in October 2021. The record indicates that this is a routine follow-up visit and no active treatment is being administered or that a unique clinical condition prevents in network providers from providing the requested services. The plan indicates that in network providers are available. 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 the continuation of care with an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty, extra wide hospital bed (E0303).
You asked the Plan to pre-approve the requested hospital bed. You say that this hospital bed is medically
necessary. The Plan denied your request. The Plan says based on the medical records provided, you do not
meet the weight requirement for the requested hospital bed.
The Plan must follow Medicare rules. Medicare has a weight requirement for this hospital bed. Based on the
medical records provided, your weight was not 350 pounds at the time the bed was requested. Therefore, we
decided that the Plan does not have to pre-approve a heavy-duty, extra wide hospital bed (E0303).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rexulti.
You asked the Plan to pre-approve Rexulti. You say that Rexulti is medically necessary. The Plan denied your
request. The Plan says Rexulti 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 selfadministered
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 Rexulti.
Benefits for Rexulti 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 acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF 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 the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen (15) 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 IRF admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for CoViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. The enrollee remains on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic mammogram and a diagnostic breast
ultrasound 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 a
diagnostic mammogram and a diagnostic breast ultrasound to be rendered by the out-of-network (OON)
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your
request. The Plan says a trial of Oral Bisphosphonates and Zoledronic Acid is required before Prolia can be
considered.
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 Prolia is
not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or
any reason they would be unsafe or ineffective for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services. 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says these services are available in network.
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 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 this provider. 
Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can be approved.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says you do not have skilled needs on an inpatient basis and you can receive a lower level of care.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs or skilled therapy needs.  You appear to be functioning at/near your baseline.  Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 surgical repair of a hip fracture 
after a fall. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says medical necessity rules for the requested drug have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that Prolia 
is not FDA-approved for your diagnosis of osteopenia (without evidence of a fragility fracture and no evidence 
of an adequate serum calcium level). The requested use of Prolia for osteopenia (without evidence of a fragility 
fracture and no evidence of an adequate serum calcium level) is not supported by one of the major drug 
compendia or by clinical research that appears 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Dupixent.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because it is not clear that
the enrollee has a confirmed diagnosis of early stages of Alzheimer's Disease or mild cognitive impairment.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved 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 Aduhelm. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Aduhelm. Our physician reviewer found
Aduhelm is Food & Drug Administration (FDA) approved for the treatment of Alzheimer's Disease in patients
with mild cognitive impairment or mild dementia stage of the disease. The documentation in the case file is
conflicting and insufficient to support a diagnosis of Alzheimer's Disease in the enrollee. The requested use of
Aduhelm is not supported by one of the major drug compendia or by clinical research appearing in a Medicareapproved 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Aduhelm.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs physical therapy and
occupational therapy for muscle reconditioning due to debility. The Plan denied your request. The Plan says
required services can safely be received in another setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be more stable, but is not a candidate for weaning, and should
only require short-term additional acute care services that may be continued safely at the current facility for
now.
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 LTACH services.