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

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right-sided facet joint nerves.
You asked the Plan to pre-approve the requested RFA procedure. You say that the enrollee has had these injections with positive effect and has even had positive effect from RFAs. This should be covered as it is shown to be beneficial. The Plan denied your request. The Plan says the criteria are not met.
The Plan follows Medicare rules. Medicare rules say that RFA of the facet joint nerves is only covered when two MBBs provide greater than 80% pain relief. 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 RFA procedure. Our reviewer says that the documentation does not support that the criteria for the requested RFA are met in this case. Our physician reviewer found the enrollee has chronic low back pain and has had only one set of right-sided MBBs at L4-L5 and L5-S1, which provided more than 80% pain relief. The current request for a right sided RFA at these levels is not medically necessary as there have not been right sided confirmatory MBBs. Therefore, at this time, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the right-sided facet joint nerves.
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 functionally, she was at high level and does
not require daily skilled therapies in an inpatient setting. Documentation does not support the need for an
admission to an SNF. The enrollee's rehabilitation needs can be met at a lower intensity level with intermittent
therapies as needed.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve. acupuncture visits.

You asked the Plan to pre-approve. acupuncture. You say that you do not want to see a neurologist and want treatment that will work without more medication. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not have chronic low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this request is not being made for chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve. acupuncture visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage for the LTACH admission.

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 transfer would not provide a significant clinical advantage at this time. There are no services at the LTACH that the member 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and a mandibular
partial denture (D5226).
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that it
would be a health hazard for you to have metal dentures because you are allergic to metal. The Plan denied
your request. The Plan says these services are not covered under your benefit plan.
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 a
maxillary partial denture (D5225) and a mandibular partial denture (D5226).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 there are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions (D7210) to be performed by an oral surgeon.
You asked the Plan to pre-approve dental extractions to be performed by an oral surgeon. You say that this is medically necessary because you are unable to eat. The Plan denied your request. The Plan says this is not covered.
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 services are not among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve dental extractions (D7210) to be performed by an oral surgeon.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (29125) provided on October 5, 2020.
You asked the Plan to pay for the services. You say that fasdfasd The Plan denied your request. The Plan says this is included in the global package.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for the listed procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. We looked at the file and Medicare rules. The services in question are included in the global surgery package for the procedure performed on October 4, 2020. Separate payment cannot be made for code 29125. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (29125) provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services beginning September 14,
2021.
You asked the Plan to pre-approve the inpatient psychiatric services. You say that the records provided support
the need for inpatient psychiatric services. The Plan denied your request. The Plan says the enrollee no longer
meets the criteria for this requested level of care.
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 the inpatient psychiatric services. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was
admitted to the acute inpatient psychiatric hospitalization on August 30, 2021, with Major Neurocognitive
Disorder Unspecified with Behavioral Disturbance. Based upon review the records provided it was not
expected this enrollee would improve in a reasonable period of time for the dates in question as she did not
have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of
care beyond the dates in question as she did not have dangerousness to self or others but was compliant with
her treatment.
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 inpatient psychiatric services have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric services beginning September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal fusion with instrumentation.

You asked the Plan to pre-approve the spinal fusion. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested procedure.

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 spinal fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no spinal instability, fracture, or lesion. There is no severe stenosis on the magnetic resonance imaging. 

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 spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal fusion with instrumentation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections (57385).
You asked the Plan to pre-approve Prolia injections. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of Zoledronic Acid or any history of pathologic fracture 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 injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the record shows not trial of the plan preferred treatment or any reason it would be unsafe or ineffective 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 Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections (57385).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device (22869, 22870).
You asked the Plan to pre-approve the Vertiflex device. You say that this treatment is considered safe and effective, as supported by its clinical benefits. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary is not met as the device has not been shown to be safe and effective in long term studies.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery (29877).
You asked the Plan to pre-approve knee surgery (29877). You say that the requested knee surgery (29877) is
medically necessary. The Plan denied your request. The Plan says the requested knee surgery (29877) 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 knee surgery (29877). Our reviewer
says that the requested knee surgery (29877) is not medically necessary. Our physician reviewer found the
enrollee was being treated for another tear of the meniscus, right knee. She presented with right knee pain that
has not improved. She has been having discomfort in the right knee for well over 4 months now. She has
continued to fail conservative measures for over 3 months. She notes mechanical symptoms with catching and
buckling of the knee. She would like to proceed with surgery. Exam reveals lower extremity strength is 4+/5 to
5/5 bilaterally. There is 1+ effusion to the right knee. There is tenderness at the medial joint line of the right
knee. Passive range of motion of the right knee is extension -3 to 5 degrees, flexion to 115. McMurray's testing
is provocative in the medial aspect of the right knee. No instability is noted.
However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be
an effective and/or safe treatment for the noted pathology (which included moderate overall degenerative
changes/knee osteoarthrosis). There is no compelling rationale presented or extenuating circumstances noted to
support the medical necessity of this request as an exception to guidelines. Therefore, the request for right knee
surgery 29877 (arthroscopy, knee, surgical: debridement/shaving of articular cartilage- chondroplasty) is not
medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of knee surgery (29877) have not been met. Therefore, we decided that the Plan
does not have to pre-approve knee surgery (29877).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for medication management services.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says out-of-network providers are only covered under limited circumstances.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for medication management services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this is needed for your health. The Plan denied your request. The Plan says the last screening exam was September 24, 2020.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that you are 80 years old. The covered age range is 55-77 years old for this request. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 this level of care is medically necessary. The Plan denied your request. The Plan says there is no need for the IRF level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for a partial nephrectomy and was treated for post-operative pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.