Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift system.
You asked the Plan to pre-approve the requested services. You say that the stair lift will help with the enrollee's
care in his home. The Plan denied your request. The Plan says a stair lift does not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a stair lift system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from January 19, 2021, to January 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided to the enrollee from January 19, 2021, to January 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that the requested proton beam radiation therapy (PBRT) is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy (PBRT) 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 proton beam radiation therapy (PBRT). Our reviewer says that the requested proton beam radiation therapy (PBRT) is not medically necessary. Our physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. Nothing in the case file suggests that these constraints cannot be met with the non-proton-based treatment, and it is not plausible that proton therapy would be needed to meet these constraints. Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton therapy will reduce the low dose to normal tissues does not necessarily demonstrate that it is clinically needed relative to IMRT though, as the reductions should be clinically meaningful, and
reduce toxicity risks in a clinically meaningful manner. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve 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 chronic back pain 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 remains experimental for back pain treatment. More research is needed. Our physician reviewer found that your 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 Intracept procedure
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the off-label use of
this drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on
the available information.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and
Drug Administration (FDA) approved 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 Retacrit. Our reviewer says that the
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our
physician reviewer found the record indicates that the enrollee has a diagnosis of iron deficiency anemia. The
record indicates that the enrollee had acute kidney injury due to dehydration and intravenous contrast injury.
Our reviewer found that the enrollee has inadequate iron intake. The FDA has not stated that the requested drug
is indicated for the enrollee's condition. Our physician reviewer also found that the Medicare approved drug
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical
situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit (Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that your records indicate that the enrollee needs routine wound
care and long term intravenous antibiotics which can be provided in the non-hospital setting and the enrollee's
care will require longer than 25 days.
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. The patient
appears to be more stable and improving and should only require short-term additional acute care services that
may be continued safely at the current facility for now. The patient does not require services at the LTACH that
are not already available at the current facility. Our physician reviewer found that the enrollee's condition does
not meet Medicare criteria for LTACH 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 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 for the enrollee.
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 LTACH is the appropriate environment
for the enrollee's continued recovery, and she is medically stable to be transferred to LTACH at this time. The
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not
require transfer to an LTACH.
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 is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
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: 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 just got a pacemaker and feel weak. You said that you want to get better so you don't fall. The Plan denied your request. The Plan says the medical records do not support the need for an intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days a week
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 are medically stable. You do not need physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You do need routine physical and occupational therapy but 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. IRF admission is not medically necessary based on lack of medical complexity, and lack of nursing needs. While you may benefit from therapy, your rehab needs can be safely met in an alternate and lower intensity 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 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 the office services (CPT code(s): 99203 and 99214) to 
be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the medical record received did not show that the enrollee has an 
emergent or urgent medical condition or is in need of specialized service. The Plan states there are multiple in network provider(s) within a reasonable distance from the enrollee's location that can provide this service/item.
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
the office services (CPT code(s): 99203 and 99214) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs treatment to maintain
her activities of daily living. The Plan denied your request. The Plan says the enrollee has non-sacroiliac joint
pathology contributing to her pain.
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 requested services. Our physician
reviewer found that the request exceeds the enrollee's medical need. Her assessment continues to list lumbar
radiculopathy, intervertebral disc degeneration, facet arthritis. A May 2021 magnetic resonance imaging (MRI)
notes moderate to severe foraminal stenosis at L5-S1 and severe central canal, lateral recess, and foraminal
stenosis at L4-5. A physical exam states that there is a negative straight leg raise for back or hip pain however
the exam does not note if the maneuver caused radicular leg symptoms which would be positive for
radiculopathy. There is no evidence of an inflammatory spondyloarthropathy (sacroiliitis) that may benefit
from this injection. There are no objective therapy notes or evidence of failure of therapy or exactly what
conservative treatment was recommended for this enrollee's pain other than injections. The documentation
does not support the medical necessity of this procedure.
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 a sacroiliac joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair (J2357).
You asked the Plan to pre-approve Xolair. You say that this is a continuation of therapy. You also say that the 
enrollee has had 3 doses of Xolair as of January 24, 2022. The Plan denied your request. The Plan says Xolair 
must be supplied by the doctor or a health care facility. The Plan also says that the records show the drug will 
be supplied by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xolair (J2357).
Benefits for Xolair 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device billed with codes E0675 and E0673 for date of service July 23, 2021.  You asked the Plan to pay for the pneumatic compression device. You say that this device is not experimental or investigational and should be covered. The Plan denied your request. The Plan says this device is not covered for the patient's condition.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 are only covered for the treatment of peripheral artery disease.  Use of this device for any other condition will be denied as not reasonable and necessary.  The diagnosis billed with this device was K50.3, which is anal fistula, not peripheral artery disease. Items coded with E0675 are not covered for this condition.  Because the compression device itself is not covered, the accessory also billed (code E0673) is also non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device billed with codes E0675 and E0673 for date of service July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from
February 21, 2022, and forward.
You asked the Plan to pre-approve the continuation of inpatient mental health care from February 21, 2022, and
forward. You say that the requested continuation of inpatient mental health care from February 21, 2022, and
forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of
inpatient mental health care from February 21, 2022, and forward is not medically necessary.
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 continuation of inpatient mental
health care from February 21, 2022, and forward. Our reviewer says that the requested continuation of inpatient
mental health care from February 21, 2022, and forward is not medically necessary. Our physician reviewer
found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted
above as he was not a danger to himself or others and did not have any delusions, auditory or visual
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not
appear that the services for the dates in question were reasonably expected or medically necessary to improve
the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan
however the entire record is not present. It appears that the services were supervised and evaluated by a
physician. Based upon review of the records provided, this enrollee does not meet the criteria for continued
treatment in an inpatient mental health setting beyond the date in question of February 21, 2022, and forward.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continuation of inpatient mental health care from February 21, 2022, and
forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation
of inpatient mental health care from February 21, 2022, and forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the procedure is investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has bilateral knee pain. Bilateral genicular nerve blocks have been requested. Genicular nerve blocks are considered investigational and not medically necessary for the treatment of chronic knee pain. Therefore, the requested blocks 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first.
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 Injectafer. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Infed and Venofer first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.
You asked the Plan to pre-approve Humira. You say that Humira is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira. Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.