Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve the Gel-One. You say that Gel-One is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says the documentation received did not support medical necessity for a step-therapy exception.
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 Gel-One. Our reviewer says that the member has not tried and failed a trial of Monovisc. Our physician reviewer found Gel-One is not approved as step therapy 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging.
You asked the Plan to pre-approve the PET/CT scan. You say that the PET/CT is needed for further treatment planning, given new finding on physical exam. The Plan denied your request. The Plan says that the PET imaging is not supported for routine follow-up of the enrollee's type of tumor and/or disease. The Plan says that the records do not show that the enrollee meets the criteria for a PET scan at this time.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says that the requested PET/CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee has had 3 malignancies. The most recent was a right upper lobe squamous cell cancer of the lung that was resected in October of 2019. A PET scan on November 26, 2019 showed a concerning area in the uvula. The enrollee is complaining of a sore throat. A repeat PET scan is needed to evaluate the area of concern, to determine whether or not the enrollee is an appropriate candidate for an invasive diagnostic or therapeutic procedure, and to determine the optimal anatomic location for an invasive procedure; or to determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. 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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symproic tab 0.2mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by this plan under any normal circumstances.
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 Symproic tab 0.2mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Avastin injection with an out-of-network provider while out of the Plan's service area.
You asked the Plan to pre-approve an Avastin injection with an out-of-network provider while out of the Plan's service area. You say that the requested out of area Avastin injection is medically necessary. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 an Avastin injection with an out-of-network provider while out of the Plan's service area. Our reviewer says that the requested out of area Avastin injection is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of exudative age-related macular degeneration, unspecified eye, stage unspecified. She is receiving intraocular injections of Avastin in her right eye every 12 weeks. Her next injection is due 2/19/20. In this case, while it would not be medically reasonable to delay the services until the enrollee returns to the Plan's service area, the enrollee knew that she would be in need of these medically necessary services prior to leaving the Plan's service area. As the requested service was foreseen prior to leaving the Plan's service, it cannot qualify as urgently needed 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 an Avastin injection with an out-of-network provider while out of the Plan's service area have not been met. Therefore, we decided that the Plan does not have to pre-approve an Avastin injection with an out-of-network provider while out of the Plan's service area.
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 you believe that this level of care is necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee underwent a total knee replacement on 2/6/2020 and was discharged the next day. Family feels care is needed due to immobility and pain. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan scan of the skull base to mid-thigh for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical information does not provide the results of a biopsy.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has had very recent CT and ultrasound exams of the pelvis and the direct visualization of the cervix with attempted biopsy did not result in complete pathologic diagnosis not only of the cervix but also the endometrium which had been questioned on the imaging reports. PET/CT is very reasonable in this light as the suspected diagnosis of cervical cancer is based upon clinical imaging and direct visualization of the cervix. Also, importantly the endometrium has been questioned on conventional imaging studies but could not be sampled due to bleeding at surgery. MRI might be of benefit for endometrial evaluation but ultimately PET/CT will provide valuable information and allow for physiologic evaluation of the complete pelvis as well as regional lymph nodes. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan scan of the skull base to mid-thigh for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Iron Sucrose intravenous (IV) Infusion.
You asked the Plan to pre-approve Iron Sucrose IV Infusion. You say that the enrollee is intolerant of oral iron preparations. The Plan denied your request. The Plan says this request does not meet Medicare criteria.
The Plan follows Medicare rules. Medicare rules say that Medicare covers Iron IV infusion when medically necessary for certain conditions. 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 Iron Sucrose IV Infusion. Our reviewer says that the Iron Sucrose IV Infusion is not medically necessary at this time. Our physician reviewer found the iron IV infusion is not needed as a first line treatment of iron deficiency anemia for a chronic hemodialysis patient receiving supplemental erythropoeitin therapy. Our doctor noted that there may be a more appropriate treatment option for this 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 Iron Sucrose IV Infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve an Iron Sucrose intravenous (IV) Infusion.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the leg for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there was no new clinical information provided to support medical necessity of this procedure.
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 MRI is not medically reasonable or necessary. Our physician reviewer found there is no recent clinical evaluation of the right knee. Most recent was in 2018. There are no PT notes concerning the right knee and no plain film report. Absent appropriate clinical criteria within the past 6 months and due to lack of monitored PT for a course of 6 weeks referable to the right knee the medical necessity of MRI of the right knee has not been established. 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 MRI of the leg for the enrollee.
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 therapy is recommended for the enrollee to live independently at home.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 records do not indicate that there are significant or complex medical and nursing issues that could not be addressed at a Skilled Nursing Facility (SNF) level of care. Ongoing medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longerduration of therapy will allow for measurable gains to be attained within a predicted period.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 inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says the necessary services may be provided to the member at a lower level of
care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The
documentation does not reveal that the member required the intensity of an IRF stay with close physician or
nursing supervision. The member does not require additional therapy or appear to be able to tolerate this
therapy on an intensive rehabilitation facility therapy program level in an IRF.
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says LTACH care is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found Long term acute care hospitals (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 including tracheostomy care, ventilator management with weaning, nebulizer treatment, suctioning, sacral wound care, surveillance laboratory studies, 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. 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: 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 you want to get back to your baseline. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on February 10, 2020 with a stroke and left-sided paralysis. You are able to walk 75 feet with assistance and a walker. You need minimal to modified assistance with activities of daily living. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not able to return home as you still need full assistance with activities of daily living. The Plan denied your request. The Plan says you can receive the necessary care in a lower level setting such as a Skilled Nursing Facility.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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 Orencia.
You asked the Plan to pre-approve the Orencia. You say that Orencia is the preferred drug due to high CCP and the enrollee's diagnosis of rheumatoid arthritis. The Plan denied your request. The Plan says the information provided does not meet the medical necessity guidelines for coverage.
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 Orencia. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has not trialed Remicad, Inflectra, and Simponi Aria. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons for why these medications were not considered. 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.