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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima.
You asked the Plan to pre-approve Truxima. You say that the requested drug is medically necessary for treating the enrollee's condition. The Plan denied your request. The Plan says Truxima is not medically reasonable and necessary as the max dose has been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Truxima. Our reviewer says that Truxima is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with diffuse large cell lymphoma. In this case, the enrollee has completed 8 cycles of Truxima. Further use of Truxima would be considered maintenance therapy for diffuse large cell lymphoma. Per the major drug compendia or by clinical research that appears in a CMS-approved medical journal, maintenance therapy for diffuse large cell lymphoma is not proven and cannot be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections.
You asked the Plan to pre-approve the Synvisc-One. You say that the enrollee should be allowed to use Synvisc-One. The Plan denied your request. The Plan says step therapy criteria have not been met. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Synvisc-One. Our reviewer says that the requested drug is not reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee has not trialed one of the Plan's preferred viscosupplemental treatments such as Euflexxa, Supartz FX, Durolane, or Gelsyn-3. Step therapy, as outlined by the plan, requires that one of the preferred agents be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not approved, as step criteria have not been 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care from July 23, 2021, forward.

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 enrollee is no longer improving in their functional abilities and /or not making significant progress in their physical and occupational therapy. The Plan states the enrollee has reached their maximum level of therapeutic benefit and they do not have any other acute care needs medically necessary.

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 is currently receiving care in an inpatient rehabilitation facility after a stroke. The facility has recommended discharged to sub-acute rehabilitation (SAR) but despite multiple accepting facilities, the family has not yet decided on a facility. Medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF care from July 23, 2021, forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need to get in better shape before you can go home. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet the Centers for Medicare and Medicaid Services (CMS) coverage criteria for an SNF admission. You have no rehab nursing needs. Your physical therapy (PT) and occupational therapy (OT) needs can be safely and effectively be provided at a long-term care facility with therapies on an infrequent basis or in home with home health care (HHC). SNF admission 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is medically stable and does not require subacute needs. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to an acute hospital on November 2nd, 2020, with complete heart block requiring Dopamine infusion complicated by V tach, PEA arrest, intubation, iatrogenic stroke, s/p pacemaker insertion, s/p thrombectomy. The enrollee was on hemodialysis for ATN, has a tracheostomy and PEG tube. Has a large unstageable sacral decubitus ulcer. Functionally he required max assist for all mobility and activities of daily living. Currently still febrile, the enrollee had an episode of hypotension, with Gram positive cocci per blood culture. The enrollee's WBC count is 16.4 as of July 29, 2021, which is still high. He is encephalopathic with an inability to follow commands or move his extremities and remains on Vent support. The enrollee's prognosis is predicted as poor and recommended palliative care consult by the treating physician. The enrollee is still hemodynamically unstable, encephalopathic and unresponsive to even verbal stimuli and on a vent support. He needs medical care in the acute setting. SNF rehab is not medically appropriate nor is it an alternative to Palliative care which is needed for his current condition. The enrollee has no ability to participate in therapies. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization.

You asked the Plan to pre-approve prostatic arterial embolization. You say that you have been on medication for 10 years, but your condition has continued to worsen. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational.

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 prostatic arterial embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is classified by multiple professional societies and expert review authorities as experimental and investigational. Prostatic arterial embolization is associated with a higher clinical failure rate compared to alternative techniques, as well as higher rates of complications including acute urinary retention.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prostatic arterial embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (36478, 99152, 99153, J3010, J2250) provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained as required by the point-of-service criteria.
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 pay for 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue as required by the point-of-service benefit criteria. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services (36478, 99152, 99153, J3010, J2250) provided on February 9, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan eye drops for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Rocklatan eye drops for the enrollee.

Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow injection services.
You asked the Plan to pre-approve fluid flow injection services. You say that the enrollee has chronic neck pain due to a prolapsed cervical intervertebral disc. You say that the enrollee has constant pain and a limited range of motion, so she is having a hard time doing basic day to day activities. You say that fluid flow is the best course of treatment for the enrollee because it is the only medication with the power to regenerate the tissues. The Plan denied your request. The Plan says the requested treatment is not FDA approved.
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 fluid flow injection services. Our reviewer says that fluid flow injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back and neck pain. She is taking Tizanidine, Gabapentin and Hydrocodone for her pain. She has a prolapsed cWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fluid flow injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow injection services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional five home health skilled nursing visits (total of 9 requested).
You asked the Plan to pre-approve the additional five home health visits. You say that it is felt that weekly nursing visits are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met with skilled nursing visits every other week.
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 the additional five home health visits. Our reviewer says that the requested additional home health care is not shown to be medically reasonable and necessary. Our physician reviewer found the enrollee is a female who has been receiving home health services. She has had intermittent skilled nursing visits for Foley catheter care and medication checks. The enrollee is noted to require a monthly Foley catheter change. There is no evidence of wound care needs or frequent medication changes. As such, the frequency of requested home health nursing services is not shown to be medically necessary and 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 the additional five home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional five home health skilled nursing visits (total of 9 requested).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan/Ruxience injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that Category 3 recommendations from the NCCN are not supported therapy.
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 injection. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found Rituximab is FDA-approved for the treatment of chronic lymphocytic leukemia (CLL) in the front line and subsequent lines of therapy. This enrollee is over 65 and plan is for single agent rituximab. This is a standard treatment option for CLL. The service is reasonable and 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Rituxan/Ruxience injection for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) visits.
You asked the Plan to pre-approve the HHA services. You say that you are not able to help with self-care any longer, and your caregiver is not able to provide this on her own. You feel that HHA services are reasonable and necessary. The Plan denied your request. The Plan says criteria for coverage of the requested HHA service are not met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 HHA services. Our reviewer says that the documentation does not support that HHA services are medically necessary to support the enrollee's treatment by skilled nursing or therapy staff. Our physician reviewer found the enrollee was recently discharged from a skilled nursing facility after a hospitalization for syncope causing a fall.
The most recent therapy documentation indicates the member is at her baseline level of function and is able to accomplish self-care tasks with minimal assistance or stand-by assistance. There is no indication that the member has a feeding tube, parental medications or complex wound care issues. There has not been a recent decline in function and the member has been medically stable. The documentation does not support that the member requires a home health aide to provide treatment that is medically necessary. The member appears to be at her baseline functional status. Her family is available to provide support with self-care tasks. The requested home health services are 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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) visits.