Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection.You asked the Plan to pre-approve the Synvisc-One injection. The Plan denied your request. The Plan says the information submitted does not meet the plans medical necessity guidelines for coverage. The plan says that the records do not show that the enrollee has had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.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 injection. Our reviewer says that the enrollee does not meet the coverage criteria for the requested injection. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve a Synvisc-One injection. Our physician reviewer found that the enrollee has not tried and failed these required drugs. Our physician reviewer found that the provided records do not indicate that the Plan's required drugs would likely be less effective and/or likely to have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Synvisc-One injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued SNF services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee is medically stable, and the care being provided is custodial.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.The fileshows that SNF services beyond December 22, 2019 were requested. 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 physician reviewer found that at the time continued services were denied, the enrollee's current level of function was maximal assist with feeding, maximal assist with grooming, maximal assist with upper body dressing, maximal/minimal assist with toileting, ambulating 5-10 feet with maximal assist, transfers with moderate assist, dependent with bathing. There are no noted daily skilled complex nursing needs. While she may benefit from continuing physical and occupational therapy, the records do not support the need for continued daily therapy after December 22, 2019. Her needs are custodial in nature.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-approvecontinued skilled nursing facility (SNF) services.
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 unable to transfer and is deconditioning across the board. You say that the enrollee is high fall risk and lives alone. The Plan denied your request. The Plan says SNF care is not medically reasonable and 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. Our physician reviewer found that, while there are identifiable skilled therapy service needs, they are not required on a daily basis. Our physician reviewer found that, as a practical matter, the enrollee does not require the necessary services on 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 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: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that daily therapy in the SNF is necessary.The Plandenied your request. The Plansaysthe enrollee's needs are custodial and she would not likely benefit from daily 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 correctin denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who fell and suffered a bimalleolar ankle fracture. She required surgical intervention and is non-weight bearing on the right leg. She currently requires maximal assist of two with bed mobility and transfers and total assist with lower body dressing. Based on available records, the patient does not meet criteria for coverage of SNF. The records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. Given her weight bearing status and prior level of function, the records do not support need for daily therapy. While she may benefit from continuing PT and OT, the records do not support the need for daily therapy.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary, as you don't want the enrollee to fall again and end up in the hospital.The Plandenied your request. The Plansaysadmission to a skilled nursing facility and receiving daily therapy would not change the likelihood that if he has recurrent bleeding and becomes hypotensive, he might fall again.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee needs daily PT and OT. There are no noted daily skilled complex nursing needs. He is ambulating household distances and requires little assistance with mobility and transfers. While he may benefit from continuing PT and OT, the records do not support the need for daily therapy.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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia (denosumab) injections.You asked the Plan to pre-approvethe Prolia injections. You say that the enrollee failed treatment with Fosamax and should be allowed to try Prolia.The Plan denied your request. The Plan says although Fosamax was failed, there has not been a trial of zoledronic acid. As such, Prolia is not considered medically necessary.Medicare covers Part B medications when they are reasonableand 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 Prolia injections. Our reviewer says that the requested Prolia is not considered medically reasonable and necessary due to the Plan's step therapy requirements. Our physician reviewer found the enrollee is a 66-year-old woman with a diagnosis of Age-related osteoporosis without current pathological fracture. There is no documented failure of the preferred medication, zoledronic acid. The documentation doesnot support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee 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 the Prolia injections have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (denosumab) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAranesp injection.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe off-label use of this drug is not medically accepted for this condition.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 injection is not medically reasonable or necessary. Our physician reviewer found you have a diagnosis of unspecified ion deficiency anemia. Review of the compendia does not support the use of Aranesp for this diagnosis. Without the support of the documentation, medical necessity cannot be determined.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-approveAranesp injection
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says you do not need multiple intensive therapies, requiring the constant supervision by a doctor and nurse who are specialized in rehabilitation to safely participate in therapy.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, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee will be restricted due to her weight-bearing limitations. The enrollee's 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 Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveXeljanz XR 11mg tablet.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysdrug coverage is limited to Medicare Part B covered drugs.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-approveXeljanz XR 11mg tablet.
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 the documentation provided supports the enrollee's need for IRF care.The Plan denied your request. The Plan says the criteria for IRF care have not 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 correctin 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/willing to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Our physician reviewer 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.
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. You say that the enrollee requires intensive therapies to restore lost function. The Plan denied your request. The Plan says you do not require full time access to a rehab doctor, or any specialized equipment.
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 were admitted with nausea, and vomiting. A CT of the chest showed findings consistent with cardiogenic edema and pulmonary disease. An MRI of the brain demonstrated a left medulla infarct. You have dysphagia and weakness, and are on a pureed diet following modified barium swallow study. You are now weaned to room air and saturating well; hemodynamics are stable. You mostly moderate assist for care and are non-toxic. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says the medical necessity criteria has not been met.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon review of the records provided for the admission of this enrollee, it does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of September 22, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any agitation or aggression but was able to contract for safety and was cooperative/compliant with treatment.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSofosbuvir-Velpatasvir tablets.You asked the Plan to pre-approveself-administered drugs. You say thatyou are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveSofosbuvir-Velpatasvir tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further informationconcerning any benefits and appeal rights.
Appeal type: Practitioner Services
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the records do not indicate that the enrollee meets the criteria for coverage of IRF care. The plan says that the enrollee does not need to be seen by a rehab doctor three times a week and does not need an intensive team for his 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 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. Our physician reviewer found that the enrollee is walking household distances of 150 feet or more with supervision. Our physician reviewer found that for transfers and activities of daily living, the enrollee's care can be addressed at a skilled nursing facility (SNF) level of care. Our physician reviewer found that the enrollee may benefit from further physical therapy, but does not require an intensive therapy program. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound of the breast to be provided by an out of network provider.
You asked the Plan to pre-approve the ultrasound of the breast from an out-of-network provider. You say that The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case are not network providers with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an ultrasound of the breast to be provided by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee is severely limited in ADLs, due to ongoing medical issues. The Plan denied your request. The Plan says there are no skilled services being received in the home at this time.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff as her needs are considered custodial in nature. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.