Persius/hicric huggingface dataset:
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 is medically stable, without intensive or medically complex needs.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 the enrollee is at moderate to contact guard assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. His hemodynamics are now stable. There is no sign of neurological deterioration. 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.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 Hyalgan 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 the requested drug is subject to step therapy. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Hyalganis not approved as step criteria is not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approveHyalgan injection for the enrollee
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 enrollee needs to go to the LTACH to continue receiving the care and the plethora of required treatments administered at consistent times without neglect or delays. The Plan denied your request. The Plan says LTACH services are not supported by the records provided. The plan says that the enrollee does not need daily doctor visits or more than 6 hours of nursing care each day.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for end-organ disease and failure to thrive. Our physician reviewer found that the enrollee appears to have been temporarily intubated/ventilated, but is no longer intubated/ventilated. Our physician reviewer found that the enrollee has a feeding tube and is unresponsive. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required and can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says SNF admission 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 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not require daily skilled nursing or skilled therapy services. The member does not require the necessary services 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to stand. The Plan denied your request. The Plan says there is no significant change from the baseline 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 physician reviewer found that enrollee was medically sick with the Flu. He was dependent for activities of daily living and mobility. He had this dependent functional status for years since stroke it is unlikely to improve with physical and occupational therapy in an IRF. Therefore, an IRF 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 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 for the enrollee.
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 4 physicians have recommended the LTACH as the best solution for the next stage of the enrollee's care. The Plan denied your request. The Plan says the services the enrollee needs could be provided in another setting. The plan says that the Medicare guidelines for coverage of LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for endocarditis. Our physician reviewer found that the enrollee is to receive a prolonged course of IBV antibiotics. Our physician reviewer found that the enrollee is not intubated/ventilated. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time that no acute services are required. Our physician reviewer found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) 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 no longer able to care for herself. You say that the enrollee is a danger to herself.The Plan denied your request. The Plan says the clinical information does not support a need for SNF care.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 the enrollee received oral medications, had stable vital signs, and had medications adjusted with effect to address her behavior. Our physician reviewer found that the enrollee received physical therapy in the acute hospital. Our physician reviewer found that the enrollee was at contact guard to minimal assist level with functional mobility, including gait to 10 feet with a rolling walker. Our physician reviewer found that there are no identifiable skilled nursing service needs. Our physician reviewer found that there are identifiable skilled therapy service needs, but that they are not required on a daily basis. Our physician reviewer found that the enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicarerules. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest during a surgical procedure. The enrollee was apparently intubated/ventilated and eventually received a tracheotomy. As of December 17, 2019 he was tolerating a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePromacta tablets.You asked the Plan to pre-approvePromacta. The Plan denied your request. The Plan says your medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. Therules 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-approvePromacta tablets.Benefits for Promactamay be available under Medicare Part D.Contactthe 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 Xeljanz XR.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are 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-approve Xeljanz XR.Benefits for these services 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-approveAbiraterone for the enrollee.You asked the Plan to pre-approveAbiraterone. You say that this is medically necessary for the enrollee.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-approveAbiraterone for the enrollee.Benefits for Abirateronemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for "the beneficiary" .You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services arenot 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for hematuria. The enrollee is not intubated or ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theLTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for "the beneficiary".
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 26, 2019.You asked the Plan to pre-approve the continued SNF care. You say that the enrollee is not independent enough yet and needs to continue to get therapy from the rehab section of the SNF.The Plan denied your request. The Plan says the enrollee no longer requires daily skilled therapy to improve or maintain her condition. Remaining 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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient is a 100 year old female with a history of falls, dehydration, chronic kidney disease, hypertension, cardiovascular disease, gastrointestinal bleed and bilateral pulmonary emboli who was admitted to the skilled nursing facility on 12/16/19 and has been discharged to long term care as of 12/26/19. Her medical status is stable as of 12/26/19. The patient is walking 125 feet with a rolling walker and also self-propels 200 feet with her wheelchair. Her balance is reported to be fair to good. She is requiring minimal assistance with ADL's.
The records do not indicate a need for skilled nursing services nor skilled therapy services. The provided medical records do not indicate a need for inpatient services. Care in the long term care facility at a custodial level of care appears to be appropriate 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 continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 26, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee needs to progress in a safe way at a facility.The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy 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 physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is dependent for care and functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lumbar spine.You asked the Plan to pre-approve the MRI. You say that you believe that this should be covered to evaluate your back pain.The Plan denied your request. The Plan says there is not sufficient evidence to support the need for an MRI at this time.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the enrollee has a history of lumbar laminectomy ad reports low back pain and numbness in the right foot. The most recent provider notes are from 2015. A record of phone calls in December 2019 to the physician office includes a request for lumbar MRI and a physician statement indicating that the enrollee should have an appointment for assessment. No documentation of any office visit or assessment by a provider was submitted. No detailed history of the current complaints or current management was submitted. MRI of the lumbar spine is not medically reasonable and 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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve an MRI of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xultophy 3.6mg/ml pens.You asked the Plan to pre-approve Xultophy. You say that Xultophy is medically necessary.The Plan denied your request. The Plan says coverage for Self-Administered drugs 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 Xultophy 3.6mg/ml pens.