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 it is felt that IRF services would be preferable. The Plan denied your request. The Plan says the enrollee is medically stable and does not require the intensive level of care from IRF. SNF admission has been approved instead.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records indicate this 75 year old status post operative repair of a trimalleolar fracture; now weight bearing as tolerated. The member is afebrile, stable, and now receiving in-home health care. The member's co-morbids include hypertension. There is a documented fear of falling. Functional status is overall supervised. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician supervision. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF or other lesser level (home health). In this case, the member is mostly standby assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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-approvesacral nerve stimulation implant.You asked the Plan to pre-approvenerve stimulation. You say that you cannot control your bladder.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not meet the Medicare criteria for this procedure.The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation implant is only covered when the enrollee has had a successful test stimulation to support implantation, and demonstrates adequate ability to record a voiding diary.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 nerve stimulation. Our reviewer says thatyou do not meet the Medicare criteria for the requested sacral nerve stimulation. Our physician reviewer found you have not had a successful test stimulation with demonstration of 50% improvement, and have not demonstrated the ability to record a voiding diary, and have not been treated for cystocele and possible stress incontinence.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approvesacral nerve stimulation implant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider. You asked the Plan to pre-approve these services. You say that you have exhausted the treatment options in New Mexico.The Plan denied your request. The Plan says the services are available from network providers.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 pre-approved care.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-approvethe medical services to be provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHumira.You asked the Plan to pre-approveHumira. You say that this is the best option for the enrolleeto achieve stability.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.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-approveHumira.Benefits for Humiramay beavailable under Medicare Part D.Contactthe 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 Repatha Sureclick.You asked the Plan to pre-approve Repatha. You say that you have failed to lower cholesterol on other medications.The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs only.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 Repatha Sureclick.Benefits for Repatha 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee requires assistance with all physical and mental care. The Plan denied your request. The Plan says that the enrollee's needs can be safely met at a lower level of care, such as, in long-term care with personal care services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFluzone High Dose vaccine.You asked the Plan to pre-approveFluzone High Dose vaccine. 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 a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Fluzone High Dose vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to Fluzone High Dose vaccine.While the influenza vaccine iscovered by your plan, the requested Fluzone high dose vaccine is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approveFluzone High Dose vaccine.Benefits for FluzoneHigh Dose vaccinemay be available under Medicare Part D.Contactthe 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-approveFerumoxytol infusion.You asked the Plan to pre-approveFerumoxytol. You say that the Ferumoxytol is medically necessary.The Plan denied your request. The Plan says coverage criteria is not 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 Ferumoxytol. Our reviewer says that Ferumoxytol is not medically necessary. Our physician reviewer found Ferumoxytol is indicated for treatment of iron deficiency anemia. The provided medical records do not document that the patient has iron deficiency anemia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ferumoxytol have not been met.Therefore, we decided that the Plan does not have to pre-approveFerumoxytol infusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee has a discharge order and the records provided support the request for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the documentation does not reveal thatthe enrollee requires the intensity of an IRF stay with close physician or nursing supervision. Our physician reviewer found that the enrollee may benefit from and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond December 30, 2019.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the continued services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the SNF on December 11, 2019 after a hospitalization with right hip surgery. You need assistance with bed mobility and transfers and are not able to walk on your own. You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to out of network provider"the provider" for a Lucentis injection.You asked the Plan to pre-approvethese services. You say that you need an eye injection while in Nevada.The Plan denied your request. The Plan says the provider is out-of-area and out-of-network.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. The file shows that you left the Plan's service area with a known need for Lucentis injections. The requested services are not for an unforeseen illness or injury. 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-approvea referral to out of network provider "the provider" for a Lucentis injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network office visit with the practice. You asked the Plan to pre-approve the out-of-network services. You say that the enrollee has had a poor experience with her current ophthalmologist.The Plan denied your request. The Plan says you must get care from a network provider .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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the ophthalmology services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services.Therefore, we decided that the Plan does not have to pre-approvean out-of-network office visit with the practice.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided.You asked the Plan to pre-approvepain management services. You say that there are no in-network pain management providers in your area.The Plan denied your request.The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.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 pre-approved care.The requested provider inthis 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. The in network provider's office is located closer to your home than the out of network provider's office. 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-approvethe medical services to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional dental extractions and alveoloplasty.
You asked the Plan to pre-approve the extractions and alveoloplasty. You say that this should be covered. The Plan denied your request. The Plan says your 2019 dental benefit only covers two extractions per year. These were approved. No additional extraction can be covered under this 2019 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, only two extractions are covered per year. Alveoloplasty is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the additional dental extractions and alveoloplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Symbicort 160-4.5 MCG inhaler (J3535).
You asked the Plan to pre-approve this medication. You say that you have severe chronic obstructive pulmonary disease (COPD) and have been on this medication for several years with good control of symptoms. The Plan denied your request. The Plan says the medication requested is not a covered benefit under your policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Symbicort 160-4.5 MCG inhaler (J3535).
Benefits for this medication 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 Plandoes not haveto pre-approvethe Gel-One 30mg/3ml injection.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe step therapy approval criteria was not met.Medicare covers Part B medications when theyare 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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found you have not trialed 
viscosupplemental treatments such as Durolane/Gelsyn-3 (hyaluronate sodium) and Synvisc/Synvisc-One (hyaluronate sodium. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gel-One is not approved as step criteria is not met.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Gel-One 30mg/3ml injection
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the cervical spine for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have a chronic history of lower extremity numbness, tingling, and weakness. Prior MRIs showed multiple areas of stenosis. It appears that the enrollee was advised to see a neurosurgeon, but did not do so. There is no evidence of new trauma, new/worsening symptoms or new/worsening findings. As such, the request for repeat MRIs is notshown to be currently medically necessary or reasonable.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-approvemagnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was involuntarily admitted to the hospital on December 26, 2019 with bipolar type schizoaffective disorder. The records do not show that the enrollee is expected to improve in a reasonable period of time, as she does not have suicidal or homicidal ideation and is not showing any aggressive behavior or agitation. She is not showing dangerousness to herself or others and is compliant with treatment. It does not appear that active treatment is taking place. The requested inpatient services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that that you would like to go to the skilled nursing facility to become stronger and to do things on your own.The Plan denied your request. The Plan says that you do not require complex daily nursing care and/or daily skilled rehabilitation therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskillednursing facility (SNF) services.