Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from February 23, 2022, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that you would like the medical records to be reviewed and the authorization to be reconsidered and approved. The Plan denied your request. The Plan says the enrollee does not have a plan or intent to harm themselves or anyone else, they are not hearing voices telling the enrollee to harm themselves or others, the enrollee is not aggressive or violent, there are no medical problems reported, and no severe side effects from medications. The Plan states the enrollee could be treated in a lower 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 decided that the Plan does not have to pre-approve continuation of inpatient mental health care from February 23, 2022, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that you would like the medical records to be reviewed and the authorization to be reconsidered and approved. The Plan denied your request. The Plan says the enrollee does not have a plan or intent to harm themselves or anyone else, they are not hearing voices telling the enrollee to harm themselves or others, the enrollee is not aggressive or violent, there are no medical problems reported, and no severe side effects from medications. The Plan states the enrollee could be treated in a lower 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the axle interspinous fixation system (CPT code 22853),
for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the clinical value and effectiveness of the axle interspinous fixation system in the setting
of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found interspinous process devices remain experimental. More research is needed to show safety and
efficacy in spine surgery.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the axle interspinous fixation system (CPT code 22853), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from June 29, 2020, to
July 23, 2020.
You asked the Plan to pay for the home health services as billed. You say that these services were medically
necessary and should be paid. The Plan denied your request. The Plan says the Q-code on this claim was not
reported correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must include a Q-code on the
same revenue code and date of service as the first visit in the episode of care.
We looked at the file and Medicare rules. The first visit on the claim was on July 1, 2020, reported on revenue
code 0421; however, the Q-code was reported on July 2, 2020, under revenue code 0551. Based on this
information, we decided that Medicare rules for coverage of the home health services as billed have not been
met. Therefore, we decided that the Plan does not have to pay for the home health services provided from June
29, 2020, to July 23, 2020.
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 you need additional therapy to help you walk
and regain muscle mass. The Plan denied your request. The Plan says you were recently discharged from SNF
care for reaching your maximum potential. You can walk 250 feet using a assistive device, so you have no
skilled needs.
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. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of your condition. TYour care needs, custodial and intermittent, and can,
as a practical matter, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 8MG DOT tablet for nausea and vomiting
(CPT code J8597), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee is using this medication to treat
nausea and vomiting associated with their migraine headaches. You state the enrollee does not have a diagnosis
related to cancer or using for chemotherapy, radiation, or post-operative nausea due to anesthesia. The Plan
denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the medication have not been met. The requested Ondansetron
8MG ODT tablet is not associated with chemotherapy treatment. Therefore, we decided that the Plan does not
have to pre-approve Ondansetron 8MG DOT tablet for nausea and vomiting (CPT code J8597), for the
enrollee.
Benefits for the medication 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 states the
enrollee's needs can be safely met in a less intensive setting. The Plan states the enrollee's care can be met in an
assisted living facility with home health services and they may also receive services you need at a long-term
care setting with part-time skilled services.
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 enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CPAP device (CPT code E0601).
You asked the Plan to pre-approve the CPAP device. You say that you purchased a CPAP in March of 2019, and it was a Phillips CPAP that was recalled last year. You state you have reached out to Phillips, and they told him it would not be until September that they can get you a replacement CPAP. You state your health is declining without using a CPAP and Phillips is not giving you any options for a replacement before September. The Plan denied your request. The Plan says there was no loss, theft or irreparable damage; therefore, the request for a new CPAP within the 5-year RUL remains denied.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. There being no loss, theft or irreparable damage within the 5-year RUL. Since the policy only allows replacement within the 5-year RUL for these reasons, and none were met. Therefore, we decided that the Plan does not have to pre-approve the CPAP device (CPT code E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279), for the enrollee.
You asked the Plan to pre-approve the services. You say that this enrollee is unable to get lasting relief from non-surgical treatments and you are requesting a minimally invasive SI joint fusion as a medically necessary and appropriate surgery to improve the enrollee's SI joint pain, function, and quality of life. The Plan denied your request. The Plan says the requested procedure is supported when the enrollee has had two separate sacroiliac (SI) joint injections to find the source of their pain. The Plan states these injections must have resulted in at least 75% pain relief and a better ability to move in ways that used to be painful. The Plan states the enrollee's records do not show this type of response from two prior injections.
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 services. Our physician reviewer found the record shows that the enrollee has sacrococcygeal disorder. The record indicates a 45% reduction in pain following injection. The record does not indicate at least 75 percent reduction of pain for the expected duration of two anesthetics (on separate visits each with a different duration of action), and the ability to perform previously painful maneuvers, following an image-guided, contrast-enhanced intra-articular SIJ injection. The elements of the coverage criteria are not satisfied. The requested service is not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279), for the enrollee.
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 require IRF care to return to your prior level of independence. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: 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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endometrial biopsy (58100), specimen handling (99000) and preventive medicine examination (99397) provided by an out-of-network provider on March 12, 2021.
You asked the Plan to pay for the endometrial biopsy (58100), specimen handling (99000) and preventive medicine examination (99397). You say that the attached records support the services. The Plan denied your request. The Plan says services should be received from network providers and CPT code 99000 is not eligible for separate payment.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the endometrial biopsy (58100), specimen handling (99000) and preventive medicine examination (99397) provided by an out-of-network provider on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion services to be provided by an out-ofnetwork (OON) provider.
You asked the Plan to pre-approve home infusion services to be provided by an OON provider. You say that 
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
providers available to the enrollee that can provide the services being requested.
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 home infusion services to be provided by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan 
denied your request. The Plan says that the requested Zilretta is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that the 
requested Zilretta is medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of tricompartmental osteoarthritis of the knee. The requested drug is being used for its current 
Food and Drug labelled indication. The Food and Drug Administration has not restricted its use to a single 
time. The elements of the coverage criteria are satisfied. The requested service is 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve
Zilretta.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance (E0485).
You asked the Plan to pre-approve an oral appliance. You say that this oral appliance is medically necessary.
The Plan denied your request. The Plan says this oral appliance is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules state that the requested oral appliance is not a covered
benefit. While this item may be beneficial for your use, it is not an item covered by Medicare or the Plan.
Therefore, we decided that the Plan does not have to pre-approve an oral appliance (E0485).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Keytruda. Our reviewer says that the
requested Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is
not FDA-approved for the enrollee's diagnosis without PDL1 testing or other testing to indicate benefit. The
requested use is not supported by one of the major drug compendia or by clinical research that appears in a
CMS-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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
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 enrollee is on long term antibiotics, 
and she cannot go home by herself. The Plan denied your request. The Plan says the LTACH services you are 
requesting do not meet the requirements for approval.
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 patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to 
an LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of 
care may be considered soon when treatment has completed.
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.