Persius/hicric huggingface dataset:
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 SNF care is medically reasonable and necessary for
the enrollee's condition. 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 the beneficiary is a 72-year-old male with
cerebrovascular accident, currently in an inpatient rehabilitation facility. In this case, there are identifiable
skilled nursing service needs and identifiable skilled therapy service needs. However, the beneficiary does not
require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet
severity of illness or intensity of service criteria for 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care for therapy. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat thermal facet joint/medial branch radiofrequency
ablation (RFA) procedure.
You asked the Plan to pre-approve thermal RFA services. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says the requested repeat thermal facet joint radiofrequency ablation is
not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the repeat thermal RFA services are 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 thermal RFA services. Our reviewer
says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the
review indicates that the enrollee is a 78-year-old female diagnosed with chronic low back pain due to lumbar
spondylosis. She has failed to respond to conservative treatment measures including physical therapy, prior
injections, and medication management. She had lumbar radiofrequency ablations ( L3,4,5) in August 2020,
without documented responses. There have not been any repeat diagnostic medical branch blocks (MBBs).
In this case, given the lack of recent confirmatory MBBs and the lack of documented response to the prior
RFAs, medical necessity for the repeat RFAs has not been established. The review has determined that the
enrollee does not meet the listed coverage criteria for the requested repeat thermal facet joint radiofrequency
ablation services. The requested services are 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 thermal RFA services have not been met. Therefore, we decided that the Plan
does not have to pre-approve repeat thermal facet joint/medial branch radiofrequency ablation (RFA)
procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
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 step therapy requirement is not 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 these services. Our reviewer says that
the services were not medically necessary. Our physician reviewer found the records show that you have knee
osteoarthritis. You have not tried and failed the Plan's required drugs, Gel-One, Orthovisc, Synvisc, Synvisc-
One, or Visco-3. The records do not show that the required drugs would have adverse effects or less effective;
therefore, Genvisc 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Genvisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing this denial. The
Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because
you can be treated at a lower outpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We 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. Our reviewer
says that you do not meet the Medicare criteria for inpatient psychiatric care. Our physician reviewer found it is
not expected that you will improve in a reasonable period of time as you do not have suicidal or homicidal
ideation noted and have no auditory or visual hallucinations. You do not show any abnormal behaviors or
symptoms that would require acute inpatient care. It does not appear medically necessary to have care provided
at the inpatient level of care rather than a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown, prefabricated post and core, endodontic therapy and periodontal scaling and root planing.
You asked the Plan to pre-approve the crown, prefabricated post and core, endodontic therapy and periodontal scaling and root planing. The Plan denied your request. The Plan says the services are not covered benefits.
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 pre-approve the crown, prefabricated post and core, endodontic therapy and periodontal scaling and root planing
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She has not tried and failed the Plan's required drugs, Durolane and Gelsyn-3. The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin composite (D2391), provided on July 22, 2021.
You asked the Plan to pay for the resin composite. You say that the service was medically necessary. The Plan denied your request. The Plan says you exceeded the Plan's allowed frequency for this benefit.
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 the resin composite (D2391), provided on July 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 12, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not request the transport. You say you should have been given the opportunity to arrange your own transport. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $250 copayment for each one-way ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services 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 ambulance transport provided on January 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for SNF care is correct.
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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that the step therapy requirement is not met. The
Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has post-menopausal
osteoporosis with high risk for osteoporotic fracture. The records do not show that she has tried and failed the
Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated
or less effective; therefore, Prolia 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of denosumab.
You asked the Plan to pre-approve denosumab. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the
documentation does not support that the enrollee has intolerance or contraindication to other available therapies
such as calcitonin, intravenous or oral bisphosphonate, raloxifene, or teriparatide.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. 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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The enrollee's Evidence of Coverage does not indicate that the Plan has
implemented step therapy criteria for Medicare Part B drugs. The Plan has not provided any other evidence to
support that denosumab may be subject to step therapy criteria. Without this information, the Plan has not
shown that the enrollee is contractually obligated to try - or otherwise have a contraindication to - certain
preferred drugs before using denosumab. Therefore, the Plan has not shown that its decision to deny
authorization for this drug is correct or justified according to Medicare rules or the Plan contract. Therefore, we
decided that the Plan has to pre-approve use of denosumab.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 this is medically necessary. The Plan denied your
request. The Plan says a discharge to an alternate level of care is recommended.
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 and do not meet the coverage criteria for this admission.
With your current medical stability, and no other medical complexity, there is no need for physician
supervision three times per week (at a minimum) for the ongoing management of any active or acute
exacerbations of chronic medical conditions. You have no acute rehabilitation or nursing needs. At your current
functional level of needing maximum assistance to total assistance, you do not require intensive therapies,
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to
daily therapy. You would not be able to make significant functional progress in a short-term acute
rehabilitation setting. Your needs are for a long period of time, and would be better served 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to make an exception to the 50-mile one way limit for routine transportation.
You asked the Plan to make an exception an exception to the 50-mile limit. You say that you need an exception to the miles for routine transportation. The Plan denied your request. The Plan says exceptions are not made for supplemental benefits.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover more than 50 miles one way for each transport. Medicare does not make exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to make an exception to the 50-mile one way limit for routine transportation.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve PriMatrix skin substitute for wound treatment 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 that the wound involves tendon.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 the services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found if the enrollee does not receive this service, according to the treating physician note, he could lose his
toe.
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 been met. Therefore, we decided that the Plan has to pre-
approve PriMatrix skin substitute for wound treatment for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
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 patient was admitted for firing of automatic implantable cardioverter-
defibrillator (AICD). Medical problems are stable. There are no complex nursing or rehabilitation needs. The
patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not
a reasonable expectation that this patient 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.