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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee is in danger of not regaining maximum function. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says the records do not indicate that the criteria for coverage have been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy, but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. The enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 that the enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. Functionally given the enrollee is dependent for all mobility and activities of daily living.He will not be able to make a significant functional recovery in an IRF in a reasonable period of time. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status with slow progress 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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing services.You asked the Plan to pre-approvethe continued skilled nursing services. You say that your father has been unable to eat, has no energy, and is not able to do the physical therapy so he has not improved. You also say that your father had less than 20 days stay with complications that were trying to be worked out, and needs more time.The Plan denied your request. The Plan says the enrollee has reached his highest level for skilled therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued skilled nursing services. Our reviewer saysthat the enrollee does not meet the Medicare criteria for continued SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of permanent leadless pacemaker (33274).
You asked the Plan to pre-approve the transcatheter insertion or replacement of permanent leadless pacemaker. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not a part of an approved study.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers leadless pacemakers when procedures are performed in studies as described above. We looked at the file and Medicare rules. The record does not show that this procedure would be provided as part of an approved study. Based on this information, we decided that Medicare rules for coverage of the transcatheter insertion or replacement of permanent leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of permanent leadless pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthe height adjustment feature is a convenience feature.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed.
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 SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and her appetite was fair. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a standby assist to supervision level with functional mobility. She required varying assist with activities of daily living. 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 SNF 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 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 waive the coinsurance for anesthesia service provided on December 30, 2019.
You asked the Plan to waive the coinsurance for anesthesia service. You say that you were told that this service would be covered by your insurance but were not told that it would be considered out-of-network. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network anesthesia service. The allowed amount of this claim is $56.73, resulting in a coinsurance obligation of $28.36. You have been asked to pay 50% coinsurance for out-of-network anesthesia service. Anesthesia service falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for anesthesia service provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI-guided SBRT.
You asked the Plan to pre-approve MRI-guided SBRT. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that SBRT is only covered for certain indications.
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 MRI-guided SBRT. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have a retroperitoneal lymph node concerning for metastatsis. The documentation does not support that the enrollee meets the LCD indications for SBRT. Therefore, the enrollee does not meet criteria for the requested 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 MRI-guided SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI-guided SBRT.
Appeal type: Other
Decision: Partially Favorable

We decided that the Plan has to pre-approve the Dexamethasone. We decided that the Plan does not have to pre-approve Palonosetron and Diphenhydramine.
You asked the Plan to pre-approve the Palonosetron, Dexamethasone, and Diphenhydramine. You say that the records provided support the need for the drugs in dispute. The Plan says that the enrollee does not meet the criteria for coverage.
We decided that the Plan has to pre-approve the Dexamethasone.
The Plan follows Medicare rules. Medicare 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 Dexamethasone. Our physician reviewer says that the coverage criteria for Dexamethasone and Benadryl meet the criteria for coverage. Our physician reviewer found that these drugs are medically reasonable and necessary for the enrollee's treatment. Therefore, we decided that the Plan has to pre-approve the Dexamethasone.
We also decided that the Plan does not have to pre-approve Palonosetron and Diphenhydramine.
The Plan follows Medicare rules. Medicare 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 for Palonosetron and Diphenhydramine. Our physician reviewer says that Palonosetron is FDA approved for moderate to high risk chemotherapy. Fluorouracil is low risk. These drugs are not FDA-approved for the enrollee's diagnosis. Our physician reviewer found that the use of these drugs for the enrollee's diagnosis is not supported by one of the major drug compendias or by clinical research that appears in a CMS-approved medical journal. These drugs are not considered medically necessary for the enrollee's diagnosis and treatment. Therefore, we decided that the Plan does not have to pre-approve Palonosetron and Diphenhydramine.
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. The Plan denied your request. The Plan says there are
no complicated wounds or multiple complicated medications which cannot be given in the current location.
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 physician
reviewer found that the enrollee was admitted to the acute care hospital with abdominal pain. The enrollee does
not require services at the LTACH that are not available at the acute care hospital where she is currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arikayce.You asked the Plan to pre-approveArikayce. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered 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-approveArikayce.Benefits for Arikaycemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services.
You asked the Plan to pre-approve the continued skilled nursing services. You say that the enrollee will need long term care at a SNF. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled therapy and his needs can be safely met at home with family assistance and home health services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued skilled nursing services. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the continued skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's rehab needs are not complex, and does not require an interdisciplinary approach with multiple specialists.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 physician reviewer found that you have been unsteady on your feet as the result of progression of chronic right lower extremity wound. You are currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you may benefit from continuing speech, physical, and occupational therapy, 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin tablets.
You asked the Plan to pre-approve Metformin. You say that the enrollee has taken Metformin for her type 2 diabetes. You also say that this drug has helped keep the enrollee's diabetes under control. The Plan denied your request. The Plan says self-administered medications are not covered. The Plan also says that this medication does not fall 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 Metformin tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional 200 units of Onabotulinumtoxin A.You asked the Plan to pre-approve the additional 200 units of Onabotulinumtoxin A. You say that you are requesting approval for this drug due to the severity of chronic migraines the enrollee has frequently. You also say that the enrollee has tried and failed beta blockers and Tegretol.The Plan denied your request. The Plan says 600 units of this medication has been approved. The Plan also says that if further use of this medication is requested, updated clinical information would need to be provided, including the specific dose being injected and the location/plan of care as to which muscles are injected.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 200 units of Onabotulinumtoxin A. Our reviewer says that an additional 200 units of Onabotulinumtoxin A does not meet coverage criteria. Our physician reviewer found the documentation does not support that the additional 200 units of Onabotulinumtoxin A injections (J0585) are medically reasonable or necessary for this enrollee. Our reviewer also found that the documentation does not support that the additional 200 units of Onabotulinumtoxin A injections (J0585) are safe and effective for the patient.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 200 units of Onabotulinumtoxin A have not been met.Therefore, we decided that the Plan does not have to pre-approve the additional 200 units of Onabotulinumtoxin A.