Persius/hicric huggingface dataset:
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 is not medically necessary.

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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 

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 an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. 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 repeat Epidural Steroid Injections (ESI) are
covered when the first injection directly and significantly provided improvement of the condition being treated
may be considered medically reasonable and necessary when the medical record documents at least 50% of
sustained improvement in pain relief and/or improvement in function measured from baseline using same scale
for at least three months.
We looked at the file and Medicare rules. Three months have not passed since the enrollee's previous injection.
Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have
not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental services to be performed by an out-of-network (OON) dentist.  You asked the Plan to pre-approve OON dental services. You say that you would like to continue to see your regular dentist. The Plan denied your request. The Plan says this dentist is OON and there are network dentists available who can perform your routine dental services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers OON dental services when the services are provided by a participating provider.   We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of OON dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services to be performed by an out-of-network (OON) dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair with power tilt and accessories.

You asked the Plan to pre-approve a group three power wheelchair with power tilt and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with power tilt and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition is causing pain
and weakness in the back. The Plan denied your request. The Plan says the service is considered experimental
and 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 a Vertiflex interspinous stabilization device was requested. Interspinous process
stabilization devices are experimental. More research is needed to show safety and efficacy. Therefore, the
requested service is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Travasol.
You asked the Plan to pre-approve Travasol. The Plan denied your request. The Plan says the drug cannot be
billed separately under the Part B benefit.
The Plan must follow Medicare rules. The rules say that parenteral nutritional therapy is only covered under
certain medical indications.
We looked at the file and the rules. The records provided do not show that the enrollee has a permanently
inoperative organ or function. Based on this information, we decided that the Medicare rules for coverage have
not been met. Therefore, we decided that the Plan does not have to pre-approve Travasol.
Benefits for Travasol 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. You say that you want to continue getting this treatment. The Plan denied your request. The Plan says this drug with inadequate blood iron levels is considered 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 Retacrit. Our physician reviewer found that you have anemia due to chronic kidney disease. Iron stores need to be adequate for Retacrit to work most effectively. You have evidence of iron deficiency based on low iron saturation less than 20%. Iron should be repleted before Retacrit is restarted to make sure it is still necessary. The service is 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced K3 foot, Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973)

You asked the Plan to pre-approve a K3 microprocessor foot. You say that the device is necessary to allow the enrollee to safely and comfortably participate in the activities he enjoys. The Plan denied your request. The Plan says the K3 microprocessor foot does not meet Medicare criteria as reasonable and 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 K3 microprocessor foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the advanced K3 foot meets the requirements listed in LCD for Medicare coverage. Despite statements from the prosthetist and the prescriber that the enrollee is a K3 ambulator, the records indicate the enrollee requires a cane for added support with ambulation. The use of cane for ambulation is not consistent with a K3 functional level. 

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 K3 microprocessor foot have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced K3 foot, Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that please reconsider for
optimal patient outcome. The Plan denied your request. The Plan says the Medicare criteria for coverage of the
requested automatic blood pressure monitor has not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve a home automatic blood pressure monitor
(A4670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on September 22, 2021.

You asked the Plan to pay for dental services. You say that you would have not gone to this dentist if you had known they were out-of-network. The Plan denied your request. The Plan says services performed by an out-of-network dentist are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the orthopedic office visit. You say that the provider was previously in-
network until they changed locations. The Plan denied your request. The Plan says the provider is out-of-
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. The records provided for review do not show that the service at
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the orthopedic
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that the drug is medically necessary. The Plan denied your
request. The Plan says the member has not met the step therapy criteria.
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
service is not medically necessary. Our physician reviewer found the member has not tried and failed the
preferred drug and the documentation does not support that preferred would likely be less effective, and/or
would likely have adverse effects for the enrollee in this case.
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 Evenity (J3111).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FERAHEME (Q0138).
You asked the Plan to pre-approve FERAHEME. You say that the drug is medically necessary. The Plan
denied your request. The Plan says the member has not tried the preferred drugs.
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 service is not medically necessary. Our physician reviewer found the records do not contain documentation
of trial and failure of Infed (iron dextran) and Venofer (iron sucrose) or support that Infed (iron dextran) and
Venofer (iron sucrose) would likely be less effective, and/or would likely have adverse effects for the enrollee
in this case.
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 FERAHEME (Q0138).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation at C2-C3 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 the documentation does not show any previous pain procedures at C2-C3.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had any diagnostic medial branch blocks at the C2-C3 level. Therefore, this request would not be considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation at C2-C3 for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex daily wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 3, 2022,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from February 3, 2022, forward. You say that the
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are
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 inpatient psychiatric care from
February 3, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health
treatment beyond the date in question of February 3, 2022, forward. Our physician reviewer found you did not
require inpatient mental health treatment beyond February 3, 2022, as you were not a danger to yourself 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 your condition or for the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from February 3, 2022, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 3,
2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain 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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee has low back pain. According to the medical records, the enrollee previously underwent bilateral lumbar medial branch blocks (MBBs) in August 2021. There are no specific physical findings related to lumbar back pain. There is no documentation of the level of pain relief from the prior MBBs, and no documentation of 80% relief related to appropriate pain scale. 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections