Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approvehome health skilled care visits.You asked the Plan to pre-approvehome health services. You say that you need a nurse to change your suprapubic catheter or you will end up in a hospital.The Plan denied your request. The Plan says that the denial of authorization for home health services is correct, because these visits are long-term care and maintenance in nature which is not covered by Medicare.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that you meet the Medicare criteria for the requested home health visits. Our physician reviewer found you are receiving monthly suprapubic catheter changes. There is no evidence that you are able to effectively perform these changes on your own. You would be at risk for secondary complications related to your conditions without the skilled nursing services being requested. The record shows that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met.Therefore, we decided that the Plan has to pre-approvehome health skilled care visits.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 continued inpatient psychiatric care beyond January 13, 2020.You asked the Plan to pre-approve the continued inpatient care. You say that it is felt that continued care in the inpatient setting is necessary.The Plan denied your request. The Plan says the enrollee's condition has stabilized and further care can be provided in a less restrictive setting.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued inpatient care. Our reviewer says that the documentation does not show that continued inpatient level care is medically reasonable and necessary. Our physician reviewer found this 63-year-old male was admitted to the acute inpatient psychiatric hospitalization on January 3, 2020 with Schizophrenia. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations, delusions and no aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have 
any suicidal or homicidal thoughts, delusions or hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee didnot require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 13, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant.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 continued inpatient care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric care beyond January 13, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond December 28, 2019.You asked the Planto pre-approve the continued SNF care. You say that you feel that the benefit should reset for the new year.The Plandenied your request. The Plansaysyour 100 day benefit is allotted per benefit period which does not end until you spend 60 days without inpatient hospital or SNF care.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from August 8, 2019 to December 28, 2019. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care beyond December 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the hospital bed. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet coverage criteria for the semi-electric hospital bed.
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 hospital bed. Our reviewer says that the member does not meet Medicare coverage criteria for the hospital bed. Our physician reviewer found does not have a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. The member does not require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain. The member does not require the head of the bed to be elevated more than 30 degrees most of the time. The member does not require traction equipment, which can only be attached to a hospital bed. She does not require frequent changes in body position and/or has an immediate need for a change in body position. 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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repair of an expandable controller for the enrollee.
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the repair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items/services at issue in this case are not medically necessary per the Social Security Act, Section 1862(a)1(A). The medical progress reports do not support or corroborate the need for the requested items/services. The medical progress reports do not indicate that these items are furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. The medical progress reports do not reveal a musculoskeletal or neurologic exam or other exam findings that indicates that the patient requires the use of the expandable controller upgrade. The expandable controller upgrade appears to exceed the patient's medical need and is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the repair have not been met. Therefore, we decided that the Plan does not have to pre-approve a repair of an expandable controller for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requirement for this drug is a MSI-H or dMMr tumor.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found this review is a request for Keytruda to treat a 69 year old woman for stage IIIc appendiceal cancer which is not MSI-H (microsatellite instability high) or dMMR (deficient mismatch repair). The requested use of Keytruda is not FDA approved nor is it supported in any of the CMS approved compendia. Therefore, the documentation does not support that the requested use of Keytruda is medically reasonable and necessary for the enrollee. The documentation does not support that Keytruda is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET Scan with CT (78816).You asked the Plan to pre-approve the PET Scan. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that FDG PET is not supported for initial staging of axillary nodes.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET Scan. Our reviewer says that the PET Scan is medically necessary and reasonable, according to the records provided. Our physician reviewer found PET scan is indicated for determining the extent of metastasis, which is appropriate at this time. Therefore, the member has an indication for which PET scan is covered.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 PET Scan have been met. Therefore, we decided that the Plan has to pre-approve a PET Scan with CT (78816).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: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued admission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is appropriate for a transition to an alternate level of care.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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve the percutaneous image-guided lumbar decompression (MILD) procedure.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 todetermine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore, it is deemed 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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe percutaneous image-guided lumbar decompression (MILD) procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveXiidra 5% eye drops.You asked the Planto pre-approvethe drops. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a medical only 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 drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveXiidra 5% eye drops.
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 you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician and nursing supervision. While the enrollee may benefit from physical therapy or occupational therapy, the enrollee does not require this on an intensive rehabilitation therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean oncology second opinion to be provided by out of network (OON) provider.You asked the Planto pre-approvethe OON second opinion consultation. You say that you have some concerns with the treatment plan recommended by your oncologist. You feel that some drugs have a high cardiac risk and you believe your heart issues may not have been considered. You also state that one of the drugs may have been discontinued. For these reasons, you believe that a second opinion from the network would not be truly independent. You believe that OON care must be approved.The Plandenied your request. The Plansaysthe network has many qualified oncologist and hematologists available to provide a second opinion. Among these are providers from the tertiary level care center,.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 Plandoes not haveto pre-approveanoncology second opinion to be provided by out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 is currently undergoing treatment at an ACH for COPD and suspected pneumonia. The enrollee is receiving antibiotics and respiratory therapies. The enrollee is not intubated/ventilated. LTACH services appear to have been requested very early during this hospitalization. The limited records submitted for review do not establish that LTACH services are going to be required. The enrollee can remain at the current acute care hospital. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysdaily skilled therapy is not necessary to restore or maintainfunction.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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled needs, but they do not need to be provided on a daily basis. You are ambulating greater than household distances and performing essential activities of daily living without hands on assistance. You are receiving care that can be provided by your non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. Your condition would not be expected to deteriorate with services provided on a less than daily basis. You have already been progressed to stair climbing and live in a single level residence. Your care can be appropriately provided through home-based and outpatient services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF)