Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Feraheme.
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary for the enrollee.
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the
Plan requires a trial of INFeD and Venofer before it will approve Feraheme.
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 Feraheme. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Feraheme. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of INFeD and Venofer. The record does
not show that these drugs would likely be less effective and/or have adverse effects 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 Feraheme have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Feraheme.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex device.  You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed. The Vertiflex device is not medically reasonable or necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound of extracranial arteries (93880) provided on June 18, 2021.  You asked the Plan to pay for an ultrasound of extracranial arteries. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules list the ICD-10-CM codes that support medical necessity and provide limited coverage for CPT codes 93880 and 93882.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultrasound of extracranial arteries have not been met. Specifically, the provided diagnosis codes of I70.0 Atherosclerosis of aorta and E04.1 Nontoxic single thyroid nodule are not listed among the codes supporting medical necessity in the Medicare rules. Therefore, we decided that the Plan does not have to pay for an ultrasound of extracranial arteries (93880) provided on June 18, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation.
You asked the Plan to pre-approve endovenous radiofrequency ablation. You say that the requested
endovenous radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the requested endovenous radiofrequency ablation.
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 endovenous radiofrequency ablation.
Our reviewer says that the enrollee does not meet criteria for the requested endovenous radiofrequency
ablation. Our physician reviewer found the documentation does not meet coverage criteria. Specifically, there
is documented tortuosity in both greater saphenous veins, a finding not addressed in the assessment and plan.
On the right there is documentation of not only tortuosity, but difficulty visualizing the vein and the reflux is
only present in focal areas of the vein. The documentation is not clear with respect to which leg is impacted.
Additionally, this enrollee has a history of hypertension, hyperlipidemia, diabetes, and impending renal failure.
The documentation does not sufficiently rule out significant peripheral artery disease in this high-risk patient, a
requirement prior to deeming bilateral greater saphenous vein ablation to be appropriate and 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 endovenous radiofrequency ablation have not been met. Therefore, we decided
that the Plan does not have to pre-approve endovenous radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that the Coflex lumbar interspinous decompression device is unproven and not
medically necessary due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The coflex device is
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Coflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health admission and
services and outpatient mental health services provided March 3, 2021, through September 1, 2021.
You asked the Plan to waive the copayment for the inpatient mental health admission and services and the
outpatient mental health services. You say that you don't feel you should have to pay for the services because
the service provided was bad. The Plan denied your request. The Plan says the outpatient services were
reprocessed with $40 copayment. The inpatient and outpatient services have had the correct copayments
applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $210
copayment per day for days 1-6 per admission for inpatient mental health care. The Plan contract also says that
you must pay a $40 copayment for each individual/group therapy session.
You have been asked to pay a total of $1,260 ($210 copayment x 6 days = $1,1260) for the inpatient mental
health admission and services provided March 3, 2021, to March 10, 2021, and a $40 copayment for each
session of outpatient mental health services. The inpatient mental health admission and services fall within the
Inpatient mental health care benefit category. The outpatient mental health services fall within the Outpatient
mental health care benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient mental
health admission and services and outpatient mental health services provided March 3, 2021, through
September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a quantity limit exception for Microlet lancets (500 per
90 days) for a non-preferred diabetic supply for the enrollee.
You asked the Plan to pre-approve the exception. You say that this is medically necessary.] The Plan denied
your request. The Plan says the criteria was not met.
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 exception. 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 uses insulin and his HgA1c is 6.4. The record indicates
that the enrollee is moving to a new location. The record provided does not document the medical necessity of
the quantity of test strips required nor does it support the use of a non-preferred product.
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 exception have not been met. Therefore, we decided that the Plan does not
have to pre-approve a quantity limit exception for Microlet lancets (500 per 90 days) for a non-preferred
diabetic supply for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met by a caregiver.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
A doctor must certify the need for home health care services. 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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesn't support that the enrollee requires skilled nursing services or a home health aide to provide treatment that is medically necessary. The enrollee does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided another setting, such as an acute
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 is currently undergoing treatment at an acute care hospital (ACH) for
sepsis in the setting of recurrent oral cancer. The enrollee was intubated/ventilated and subsequently received a
tracheotomy. The enrollee is tolerating ventilator weaning. Decannulation is not expected. 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 long term care 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 admission to a long term acute care hospital (LTACH) 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 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 enrolle'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 acute myeloid leukemia and was discharged home with home health services. There has been functional decline since discharge. 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility services.  You asked the Plan to pre-approve continued skilled nursing facility services. You say that further skilled services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at 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 continued skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows the enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of January 19, 2022, the member required custodial services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility 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 enrollee lives alone and falls all the time. The appellant says that the enrollee needs to be back to 100% before going home. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met at a lower, less intensive 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 enrollee suffers from debility from vertebral fracture and pain and is medically stable. With her comorbid conditions being stable, she does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehabilitation nursing needs noted in the record. The enrollee does 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. IRF admission is not medically necessary based on lack of medical complexity, and rehabilitation nursing needs. While the enrollee may benefit from physical and occupational therapy, the enrollee's rehabilitation 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: 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 she 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 Vertiflex superion device placement surgery.
You asked the Plan to pre-approve Vertiflex superion device placement surgery. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Vertiflex superion device placement
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal
stenosis with neurogenic claudication. The record indicates that the enrollee has had imaging studies over 18
months ago that showed multi-level disease. There are no recent imaging studies to evaluate the enrollee's
condition. The record does not document that the enrollee is not indicated for operative intervention at no more
than two levels. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex superion device placement surgery have not been met. Therefore, we
decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.