Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee returning home will jeopardize their health. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee will benefit from skilled therapy and skilled nursing services as their recover from this recent spine infection. The Plan states the enrollee will need intravenous antibiotics, and they can safely receive the services they need in other settings, for example: a skilled nursing facility, or perhaps home with home health services.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar discitis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is intended for use in a skilled nursing facility.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that the device is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services you need in another setting, for example: at a skilled nursing facility.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for atrial fibrillation, pneumonia, and confusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for bacteremia and osteomyelitis and had a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve chiropractic services.  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 provider did not provide additional clinical information to show medical necessity for the requested services of additional chiropractic visits.  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.   Despite multiple attempts by the plan, records were not received for this request. It cannot be determined if you have a covered condition for the requested services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve NMES, electronic shock unit (CPT code E0745), electrical stimulator supplies, 2 lead (CPT code A4595), and form fitting conductive garment for delivery of tens or NMES (CPT code E0731) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.  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 NMES, electronic shock unit (CPT code E0745), electrical stimulator supplies, 2 lead (CPT code A4595), and form fitting conductive garment for delivery of tens or NMES (CPT code E0731) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic parenteral drugs, two or more administrations, different medications (D9612), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 13, 2021.  You asked the Plan to pay for the therapeutic parenteral drugs, deep sedation/general anesthesia and tooth extraction. You say that you would like these services covered. The Plan denied your request. The Plan says these services are not covered because they were rendered by a provider who has opted out of Medicare.  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 the therapeutic parenteral drugs, deep sedation/general anesthesia and tooth extraction when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.   We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the therapeutic parenteral drugs, deep sedation/general anesthesia and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drugs, two or more administrations, different medications (D9612), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee is clinically stable for discharge and appropriate for transfer. You say that the clinical documentation supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.  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 appears to be improving, but still requires additional short-term acute care hospital services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the clinical value and effectiveness of Keytruda in the absence of microsatellite instability-high (MSI-H), deficient MisMatch Repair (dMMR), or High Tumor Mutational Burden (TMB-H) status have not been demonstrated in the peer-reviewed literature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Reblozyl.  You asked the Plan to pre-approve Reblozyl. You say that it is obvious that Retacrit is failing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Reblozyl is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Reblozyl. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Reblozyl. Our physician reviewer found Reblozyl is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. There is no documentation of need for a blood transfusion or that the enrollee is not iron deficient. The requested use of Reblozyl is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Reblozyl.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for low back pain. More research is needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1851).  You asked the Plan to pre-approve the knee orthosis. You say that the knee brace is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that for a knee orthosis using codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852 to be covered, knee instability must be documented by examination of the beneficiary.  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 knee orthosis. Our reviewer says that the knee orthosis is not medically necessary. Our physician reviewer found there is no documentation that the requested knee orthosis meets Medicare criteria for medical necessity. Provided medical records do not document recent knee injury or surgery, or knee instability on examination.  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the care could be received 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 based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve open sacroiliac (SI) joint fusion and mesenchymal stem cell therapy along with an associated inpatient admission.  You asked the Plan to pre-approve open SI joint fusion and mesenchymal stem cell therapy with an associated inpatient admission. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve open SI joint fusion and mesenchymal stem cell therapy with an associated inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found SI joint fusion criteria is not met. There is no SI joint instability, fracture, or lesion. Stem cell therapy is experimental at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of open SI joint fusion and mesenchymal stem cell therapy with an associated inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve open sacroiliac (SI) joint fusion and mesenchymal stem cell therapy along with an associated inpatient admission.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve routine transportation (A0120).  You asked the Plan to pre-approve routine transportation. You say that you prefer this agency for transportation. The Plan denied your request. The Plan says your benefit only allows for transportation services arranged through the Plan's transportation vendor.  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 covers routine transportation when only when the Plan's routine transportation vendor is utilized.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, routine transportation is only covered when the Plan's vendor is utilized. Therefore, we decided that the Plan does not have to pre-approve routine transportation (A0120).