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 this is medically necessary.The Plan denied your request. The Plan says you can be treated in other settings.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 based on the medical records provided, there is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Continued 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-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from intensive inpatient
rehab to optimize mobility, and regain the ability to perform activities of daily living. The Plan denied your
request. The Plan says the enrollee does not need intensive therapy, or supervision by a rehab doctor three
times a week.
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 has progressively worsening weakness. His past medical history is notable for Parkinson's
disease, heart disease and advancing dementia. He is 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 he may benefit from continuing speech, physical, and occupational therapy, the
documentation does not support that an intensive therapy program with therapy 3 hours per day with frequent
physician oversight and an interdisciplinary approach to rehabilitation care are needed.
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 Plandoes not haveto pre-approveFluorouracil solution 1mg/20mlYou asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis application is out-of-evidence and requested for a use not indicated by the FDA.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 thedrug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a stage III sigmoid colon cancer resected in 7/2019. He is high risk based on a high grade tumor. It is unclear why adjuvant chemotherapy is being delayed this much. The plan is for chemotherapy with FOLFIRI which utilizes fluorouracil in combination with irinotecan. Irinotecan is not indicated for adjuvant chemotherapy for colon cancer. Standard is fluorouracil in combination with capecitabine or oxaloplatin. The service is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveFluorouracil solution 1mg/20ml.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from June 23, 2019 to July 31, 2019.You asked the Plan to pay forthe skilled nursing services. You say that you have attempted to gather medical information to support the enrollee's need for skilled nursing services, but the facility states that the records prior to July 1, 2019 are not available.The Plan denied your request. The Plan says the enrollee's rehab and medical needs could be met at a lower level of care with intermittent therapy and nursing in a community setting.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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 23, 2019 to July 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX.You asked the Plan to pre-approveSupartz FX (J7321). You say that you wantthe enrollee treated with this drug.The Plan denied your request. The Plan says the enrollee has not first tried and had a 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 Supartz FX (J7321). Our reviewer says that criteria is not met for this drug. Our physician reviewer found the enrollee has not tried and failed Orthovisc and Monovisc The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverseeffects 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 Supartz FX (J7321) have not been met.Therefore, we decided that the Plan does not have to pre-approveSupartz FX.
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 an LTACH is the appropriate level for treatment of respiratory and comorbid conditions. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care, and does not require transfer.
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 LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management and tracheostomy care, intravenous antibiotics, surveillance laboratory studies, total parenteral nutrition or tube feeding, 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 14, 2020 to January 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other than a SNF. 
 
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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 14, 2020 to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast prosthesis provided on March 9, 2020.
You asked the Plan to waive the coinsurance for the breast prosthesis. You say that the prosthesis was approved and you should not have to pay the coinsurance. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 20% coinsurance for medical supplies. You have been asked to pay $16.25 which is 20% of the allowed amount for the breast prosthesis. The allowed amount is $81.24. ($84.24 x 20% = $16.25). The breast prosthesis falls within the "Prosthetic devices and related supplies" 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 the breast prosthesis provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility 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 not medically stable. The enrollee still requires acute interventions in the hospital and will not be able to participate in an intensive rehabilitation therapy program. Functionally given she requires assistance with activities of daily living and mobility. The enrollee may benefit from 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 medical instability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system, seal elevation feature, and armrest components for a power wheelchair. You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the enrollee's upper limb strength and function is adequate for the enrollee to control the power options using their own switches. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that an expandable control system was 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 the requested items. Our physician reviewer found that the enrollee has a diagnosis of incomplete paraplegia. His upper extremity strength is a 4+/5 bilaterally. There is no information in the record justifying the need for control of the power options through the joystick. The enrollee's physical function and strength indicate that he could control separate switches for the power functions. Therefore, an expandable control system is not medically necessary. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. We looked at the file and the rules. A seat elevation system is not primarily medical in nature. Based on this information, the Medicare rules for coverage have not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The requested armrests are included in the approved power tilt and recline features. The armrest components as coded by K0108 have not been billed correctly. We looked at the physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable control system, seal elevation feature, and armrest components for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a male vacuum erection system (L7900).
You asked the Plan to pre-approve the male vacuum erection system. You say that the vacuum system is
medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Vacuum Erection Devices are not a covered
item.
We looked at the file and Medicare rules. This item is statutorily non-covered by Medicare. Based on this
information, we decided that Medicare rules for coverage of the male vacuum erection system have not been
met. Therefore, we decided that the Plan does not have to pre-approve a male vacuum erection system (L7900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that for a continuous glucose monitor to be covered, the
enrollee must be insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered
continuous subcutaneous insulin infusion pump.
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 continuous glucose monitor. Our
reviewer says that the continuous glucose monitor is not medically necessary. Our physician reviewer found
the enrollee does not use insulin. The records do not show any reason a conventional glucometer would not
meet the needs of 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 continuous glucose monitor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on February 11,
2020.
You asked the Plan to waive the deductible for the office visit. You say that you had a procedure on your colon
and were told there would be no charge. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $198 deductible that applies towards provider and professional
services at an in-network PCP's office or specialist's office.
The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $198 deductible that applies towards provider and professional services at an innetwork
PCP's office or specialist's office. The record shows you received an office visit.
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on
February 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office
visit provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there are other services that may be available as part of the mental health benefit.
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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not
meet the criteria for treatment in an acute inpatient mental health treatment beyond May 27, 2020 forward, and
could be treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation,
auditory or visual hallucinations, delusions, and you were not showing any behaviors or aggression. You were
cooperative and compliant, while not showing any acute threats to safety.
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 Plan does not
have to pre-approve admission to an inpatient mental health facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. 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 medically necessary.
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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Age-related osteoporosis without current pathological fracture. The documentation does not support that the enrollee is tried and failed the required drug of Zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective. and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.