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

We decided that the Plan does not have to pre-approve treatment with Evenity (J3111).

You asked the Plan to pre-approve Evenity. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not
been met.

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 Evenity. Our reviewer says that the
requested drug is not medically necessary in this case. Our physician reviewer found that the Plan requires a
trial of drugs Forteo and Tymlos before they will approve the requested drug. In this case, the enrollee has not
tried and failed the required drugs. There is no documentation provided indicating that the Plan's required
drugs would likely be less effective and/or likely 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve treatment with Evenity (J3111).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March
12, 2021, to April 10, 2021.

You asked the Plan to pay for the SNF service. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at
an inpatient skilled nursing facility (SNF) 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 pay for the SNF service. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled
nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a SNF setting.

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 SNF service have not been met. Specifically, the file indicates that the
enrollee did not receive skilled services on the dates of service in this case. Therefore, we decided that the Plan
does not have to pay for the skilled nursing facility (SNF) care provided from March 12, 2021, to April 10,
2021.
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. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee will need or fully benefit from the intensity of services in an IRF.
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 physician reviewer found that the enrollee is medically stable with debility and a recent stroke. There is no other medical complexity, to require a physical medicine physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions.
Functionally, she is at a high level for bed mobility, transfers, and ambulation. The documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections.

You asked the Plan to pre-approve the requested services. You say that the enrollee suffers severe and persistent pain. The Plan denied your request. The Plan says the enrollee has not failed to improve following 4 weeks of standard treatments.

The Plan follows Medicare rules. Medicare rules say that epidural injections for pain management are only covered under certain medical indications. 

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 services. Our physician reviewer found that the enrollee has low back pain secondary to lumbar myofascial pain, lumbar disc displacement, lumbar radiculopathy, lumbar facet arthropathy. He has been treated with medical therapy and physical therapy. Bilateral transforaminal epidural steroid injections at 2 levels (L4-5, L5-S1) were recommended. In this case, the request for bilateral transforaminal ESIs at 2 levels does not meet Medicare LCD criteria. It is considered not medically reasonable or necessary to perform more than 2 epidural injections in a single setting (e.g., single level bilaterally or two levels unilaterally). The review has determined that based on the rules and records provided, the enrollee does not meet the coverage criteria for the requested injections. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections.
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 the SNF services. You say that the enrollee needs antibiotics, has a wound
vacuum, and needs physical therapy. The Plan denied your request. The Plan says the requested SNF stay is not
medically necessary.
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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the medical record is reviewed in its
entirety. The enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does
not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care
than a skilled nursing facility. The enrollee does not have any parental medication; daily complex wound care
or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic
medical problems. Her physical function appears to be at a new baseline, and she will continue to require
assistance including custodial care. Admission to a SNF for inpatient skilled rehab services is not medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 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 sclerotherapy (36471).

You asked the Plan to pre-approve sclerotherapy. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated.

 We looked at the file and Medicare rules. The records show that the enrollee has saphenous reflux. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy (36471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a power wheelchair. You say that you are in the process of becoming in-network. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 a power wheelchair to be provided by an out-of-network (OON) provider
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 need inpatient rehabilitation care in order to be
able to recover fully and live safely. The Plan denied your request. The Plan says the criteria for admission to
an IRF are not met. You can safely receive the services you need in another setting.
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.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral blepharoplasty.

You asked the Plan to pre-approve a bilateral blepharoplasty. You say that this request is medically necessary.
The Plan denied your request. The Plan says the coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that the blepharoplasty is subject to the criteria listed 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 a bilateral blepharoplasty. Our reviewer
says that the requested procedure is not medically necessary. Our physician reviewer found the documentation
does not support that there is interference with vision or visual field, related to activities such as difficulty
reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow
fatigue. It is not documented that there is a margin reflex distance (MRD) of 2.5 mm or less, and a difference of
12? or more or 30% superior visual field difference is demonstrated between visual field testing before and
after manual elevation of the eyelids.

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 bilateral blepharoplasty have not been met. Therefore, we decided that the
Plan does not have to pre-approve a bilateral blepharoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Spinal Q Taping Shirt to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a Spinal Q Taping Shirt. You say that this item would make a difference in your health. The Plan denied your request. The Plan says back braces 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 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 a Spinal Q Taping Shirt to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis anterior interbody decompression cervical below C2 (22551). arthrodesis anterior interbody lumbar (22558), arthodesis posterior/posterolateral lumbar (22612), discectomy. anterior, with decompression of spinal cord and/or nerve root(s) (63075), and vertebral corpectomy (63081).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that incorrect codes were requested.

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. More conservative measures for back pain must be tried and failed. More physical therapy is needed. 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 arthrodesis anterior interbody decompression cervical below C2 (22551). arthrodesis anterior interbody lumbar (22558), arthodesis posterior/posterolateral lumbar (22612), discectomy. anterior, with decompression of spinal cord and/or nerve root(s) (63075), and vertebral corpectomy (63081).
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 transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee is not medically stable for transfer and is receiving the appropriate care in
the current acute-care facility.

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 receiving acute care services, and these have not been denied
by the Plan. The medical record does not indicate that the enrollee requires services that they are not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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 impression and custom preparation; oral surgical splint (21085) for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee is experiencing pain in her right temporomandibular joint. The Plan denied your request. The Plan says that this is not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve impression and custom preparation; oral surgical splint (21085) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in the setting of low back pain, lumbosacral degeneration, and lumbosacral spondylosis has 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The intracept procedure is experimental. More research is needed to show efficacy and safety for low back pain treatment. Our physician reviewer found that the enrollee's condition does not meet criteria for 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 Intracept procedure for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing and skilled therapy services.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a right arm fracture and had surgical repair seven months ago. You are medically stable and have been taught a home exercise program. There is no documentation that you have a feeding tube, require medications taken other than orally, or complex wound care needs. There has not been a recent decline in your function. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program, or maintain your condition and/or prevent deterioration. The home health services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing and skilled therapy services.