Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee has restorative potential and you feel that SNF admission is appropriate.The Plan denied your request. The Plan says that the enrollee appears to be better than her baseline and it does not appear that the enrollee's restoration potential is significant and that the condition of the enrollee will improve materially in a reasonable and generally predictable period of time.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-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that you have been on Prolia for quite a while, and need to continue taking it.The Plan denied your request. The Plan says your plan does not cover outpatient prescriptiondrugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The 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-approveProlia.Benefits for Proliamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveGenvisc injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansays the preferred viscosupplements are Orthovisc and Monovisc, and don't require authorization.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the appeal considers the request for Genvisc for the treatment of osteoarthritis in the right knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. 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, Genvisc 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveGenvisc injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be provided at SNF level of 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 enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveTacrolimus 0.5mg capsule.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.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-approveTacrolimus 0.5mg capsule.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH).You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The PlansaysEntity the services could be provided 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 carefullyreview 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 a groin infection following an AAA repair. The enrollee has received surgical debridement, wound care and antibiotics. The enrollee has also lost the function in one kidney, but has not been started on hemodialysis. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips that you preferred.You asked the Plan to pre-approvethese services. You say that you have been using these test strips for years.The Plan denied your request. The Plan says it is not a preferred brand.The Plan must follow Medicare rules. The rules say that plans may limit beneficiaries to preferred providers for durable medical equipment and supplies. The contract with the Plan states that there are preferred providers for diabetic supplies. The test strip brand you preferred is not a preferred provider with the Plan. The Plan covers test strips of certain brands.Therefore, we decided that the Plan does not have to pre-approve the test strips you preferred.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lower partial denture -flexible base.You asked the Plan to pre-approvethe dentures. You say that you had an allergic reaction to your previous lower partial dentures. The Plan denied your request. The Plan says this is not a covered 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. The health plan only covers specific codes for dentures.D5226 is not listed as a covered code for dentures in your contract. 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-approvea lower partial denture -flexible base.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that the enrollee can receive the care he needs in another setting, such as home, a long-term care facility, or other outpatient setting.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-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysalternate settings can be requested and reviewed.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean MRI of the brain for "the beneficiary".You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is insufficient clinical information to approve this study.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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee had an extensive eye exam by an optometrist on 10/25/19 but unfortunately the entire visit is hand written and largely illegible. There is a notation concerning ocular migraines and a recommendation for a carotid ultrasound (results unknown). The optometry exam may include visual abnormalities that warrant MRI however the record is largely illegible. The reason the plan has denied the MRI scan is the lack of an abnormal eye exam and a valid indication for MRI. While the exam is in the records submitted, the indication for MRI is not obvious.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 MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean MRI of the brain for "the beneficiary".
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve11 skilled nursing home health visits (G0299).You asked the Plan to pre-approve11 skilled nursing home health visits. You say that you need assistance with medication and wound care.The Plan denied your request. The Plan says Medicare criteria have not been met for a skilled nurse.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 11 skilled nursing home health visits. Our reviewer says that the requested home health care is not medically necessary at this time. Our physician reviewer found the medical records do not show that home health aide skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient. The patient's wound care is not at a complexity that requires the skills of a professional nurse. The patient has had prior wound care with education. The patient's needs can be performed by a non-skilled caretaker. The patient's wound is also monitored weekly at a wound care clinic.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 11 skilled nursing home health visits have not been met.Therefore, we decided that the Plan does not have to pre-approve11 skilled nursing home health visits (G0299)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient hospital detoxification services.You asked the Plan to pre-approvethe inpatient hospital detoxification services. You say that the enrollee has chronic nonmalignant pain and has been on multiple medications. You say that the enrollee has significant comorbidity and a profound anxiety disorder. You say that theenrollee requires a brief inpatient hospitalization for nursing observation while she is medically withdrawn from multiple medications. You say that the enrollee is not psychiatrically stable enough to entertain attempting this on an outpatient basis. Yousay that the enrollee should be observed for signs of psychiatric decompensation.The Plan denied your request. The Plan says the enrollee can receive these service in a short-stay observation setting.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 inpatient hospital detoxification services. Our reviewer says that an inpatient admission is not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not support a medical condition that clearly warrants inpatient detoxification. Our physician reviewer found that the provider indicates that the enrollee has a co-occurring substance use disorder; however, there is no documentation ofsubstance use disorder with potential for life-threatening withdrawal which is active 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 the inpatient hospital detoxification services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient hospital detoxification services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that you are stable and now ready for discharge.The Plandenied your request. The Plansaysthere are no skilled needs.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 correctin 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. You do not require skilled nursing or therapy services on a daily basis. You do 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-approveadmission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is still ill and just completed the administration of IV antibiotics for pneumonia. You say that you are currently working on a discharge plan to home with the enrollee and her family.The Plan denied your request. The Plan says the services the enrollee needs do not warrant a long term acute care inpatient rehabilitation admission and can be provided in the home , or at an alternate level of care.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 provided medical records show that a lower level of care at a skilled nursing facility or sub-acute rehabilitation facility is reasonable and appropriate as of December 23, 2019. Our physician reviewer found that the enrollee was stable for transfer to 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that there was no occupational or physical therapy evaluation or documentation of the need for daily skilled nursing to support the admission to a skilled nursing facility.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-approveskilled nursing facility (SNF) services for the enrollee.
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 IRF care is medically necessary.The Plan denied your request. The Plan says the records do not show that that the enrollee meets the Medicare guidelines for coverage of services in an IRF.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 enrollee does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Our physicianreviewer found that the enrollee's care needs can be met at 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 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.