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

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not have acute symptoms that require 24 hour care.
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary in this case. You do not appear to require inpatient mental health treatment beyond the date in question as you are not a danger to yourself or others and have no auditory hallucinations or visual hallucinations while being cooperative with treatment. It does not appear that active treatment was taking place beyond the date in question. It does not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not support the medical necessity criteria for a high frequency chest wall oscillation device.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 a HFCWOD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has COPD. The medical record indicates a diagnosis of bronchiectasis, but there is no CT scan interpretation to support this. There is no indication that other clearance measures have been tried and failed, such as a flutter valve. There is no information in the record to support the note addendum that the patient has had frequent exacerbation. A HFCWO device 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 a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine.
You asked the Plan to pre-approve the Lidocaine. You say that you would like reconsideration because the Lidocaine is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's condition under their Medicare Part B 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-approve Lidocaine.
Benefits for the Lidocaine 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 pay for the skilled nursing facility (SNF) services rendered from February 1, 2020 to February 9, 2020 and from February 13, 2020 to February 19, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for a urinary tract infection and sepsis. He had uncomplicated wound care and stable vital signs. He received physical, occupational, and speech therapy in the SNF.
By the dates in question, he needed moderate to maximal assist with gait to 100 feet and varied assist with activities of daily living. He had no skilled nursing needs. He had skilled therapy needs but did not require skilled therapy on a daily basis. As a practical matter, the enrollee did 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 pay for the skilled nursing facility (SNF) services rendered from February 1, 2020 to February 9, 2020 and from February 13, 2020 to February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says medical conditions are stable and successfully managed, with oral medications that do not require adjustment or titration.
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. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR, HHS). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz XR 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 medication 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 Xeljanz XR for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need additional care. The Plan denied your request. The Plan says that your needs are custodial in nature.
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be met at a lower 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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR,
HHS, LTC).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information indicates that needs can be safely met in the current hospital setting, if ordered by the doctor.
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 was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally given his high level of function as described above, he does not require IRF level of therapies and does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the chest.
You asked the Plan to pre-approve CT scan. You say that you are appealing with records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has a history of fusiform thoracic aortic aneurysm with a history of hypertension and hyperlipidemia. The enrollee has not had a re-evaluation of the aneurysm in approximately 3 years. It is medically reasonable, necessary, and good clinical practice to follow the aneurysm with serial CT or Magnetic Resonance Imaging (MRI) scans to continue to assess it for increasing size, especially given the history of hypertension. Since no follow-up study has been done in the past 3 years it is medically necessary to reassess the enrollee's condition 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the chest.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Latuda 40mg tablets.
You asked the Plan to pre-approve Latuda. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
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 Latuda 40mg tablets.
Benefits for Latuda 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 Plan does not have to pre-approve additional units of Pemetrexed and Pembrolizumab for the enrollee.
You asked the Plan to pre-approve the additional units. You say that this is medically necessary. The Plan denied your request. The Plan says this can be reasonable and necessary for a duration of twelve weeks to allow sufficient time for the enrollee to continue with the current treatment plan, and undergo imaging to determine if there is disease stability or progression.
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 additional units. Our reviewer says that the requested additional units are not medically reasonable or necessary. Our physician reviewer found at this time the documentation does not support that drugs are medically reasonable and necessary for the enrollee. beyond the approved 12 weeks. The submitted documentation states she had radiation to the left lung in 2/2020. No reason is stated. The enrollee was on maintenance chemotherapy with the stated agents at that time. In the opinion of this reviewer, there is insufficient information to determine whether she had progression of the cancer at that time. If so, then the maintenance chemotherapy was not effective and alternative systemic therapy would possibly have been indicated at that time. (NCCN Guidelines Version 6.2020 Non-Small Cell Lung Cancer page NSCL-32.) There are no imaging reports other than brain imaging since 5/28/20 so it the current status of other metastases are not documented. 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 units have not been met. Therefore, we decided that the Plan does not have to pre-approve additional units of Pemetrexed and Pembrolizumab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this si medically necessary. The Plan denied your
request. The Plan says chronic conditions have been well controlled, with minimal assistance required for
activities.
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.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toujeo Solostar 300 unit/ml.
You asked the Plan to pre-approve Toujeo Solostar 300 unit/ml. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Toujeo Solostar 300 unit/ml.
Benefits for Toujeo Solostar 300 unit/ml 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says that although skilled therapy is needed, the enrollee would not be able to participate.

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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs (in particular the wound care) do require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require treatment by multiple therapies, including physical therapy and occupational therapy, and an intensive rehabilitation therapy program. There is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 

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 been met. Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee's ongoing care needs include respiratory support with oxygen supplementation, surveillance laboratory studies, close fluid balance with intermittent diuretics, ongoing diet advancement, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.