Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 23 additional speech therapy visits.You asked the Plan to pre-approve the 23 additional speech therapy visits. You say that you require the therapy being requested in order to progress towards eating all of your meals orally. You say that it is not safe to return to your home at this time and you need to get stronger.The Plan denied your request. The Plan says the number of visits that have been approved are sufficient for the enrollee's care at this time. The plan says that the remaining number of speech therapy visits are not medically reasonable and necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 23 additional speech therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee was instructed in a home exercise program and the documentation does not reveal extenuating factors that would require additional speech therapy beyond what was already approved for the enrollee. Our physician reviewer found that additional speech therapy sessions do not require services to be safely and effectively performed only by a therapist, or under the supervision of a therapist. Our physician reviewer found that the enrollee and caregiver both were 100% compliant in safe swallowing strategies.
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 23 additional speech therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve23 additional speech therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network (OON) provider.
You asked the Plan to pre-approve the OON dermatology services. You say that the enrollee has been seen by dermatologists and was dissatisfied with the care provided. He feels that the OON provider should be approved due to this. The Plan denied your request. The Plan says there are other network providers that the clinic as well as dermatologists at the clinic who can provide the necessary services. As there is no network deficiency, there is no need for OON approval.
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 is not a network provider 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 the medical services to be provided by out of network (OON) provider.
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 enrollee would benefit from treatment in an IRF program.The Plan denied your request. The Plan says it is not expected that the enrollee will be able to tolerate three hours of daily therapy. The requested IRF care exceeds the enrollee's 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 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 wide resection of femur with endoprosthesis due to fibrous dysplasia. The post-op course has included pain management, and 50% partial weight bearing for the right lower limb. The member is hemodynamically stable, and afebrile. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician supervision in an acute hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly standby assist for functional transfers and ADL's and a less intensive, longer duration 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: SNF
Decision: Favorable

We decided that the Planhasto pre-approvecontinued skilled nursing facility (SNF) care beyond January 5, 2020.You asked the Planto pre-approvethe SNF care. You say that the enrollee needs to receive continued care in the SNF setting.The Plandenied your request. The Plansaysthatthe enrollee does not require skilled nursing services on adaily basis any longer.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 care. Our reviewer says that the documentation supports that daily skilled services continue to be required for this enrollee's condition. Our physician reviewer found the enrollee does have documented skilled nursing needs. The enrollee is receivingdaily wound care and daily IV antibiotics. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to ADLs with minimal supervision. Daily skilled nursing services are required to establish amaintenance program and/or to prevent deterioration of the enrollee's condition.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 care have been met. ThePlan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Planhas to pre-approvecontinued skilled nursing facility (SNF) care beyond January 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve device to place in the chest area to stimulate breathing
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says due to lack of sufficient review of published literature, phrenic nerve stimulation is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider services billed with CPT 0424T to be medically reasonable or necessary. The requested device is coded with CPT 0424T. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve device to place in the chest area to stimulate breathing
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device to be provided by out of network provider.
You asked the Plan to pre-approve a power mobility device. You say that your knees are getting weaker. The Plan denied your request. The Plan says that this is available in network.
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 is not a network provider 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 a power mobility device to be provided by out of network provider.
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 IRF care would provide the best chance for full recovery.The Plan denied your request. The Plan says the enrollee is medically stable and her needs can be met in SNF.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 is a 67-year old female hospitalized on December 29, 2019 following a fall with a fracture of the left shoulder. She had impacted comminuted fracture of left proximal humerus. Treatment was non-operative approach with no weight bearing on the left shoulder. Therapy notes of January 7, 2019 indicate she was heel weight bearing on the left foot and non-weight bearing on the left shoulder. Functionally, she was stand by or contact guard assist for transfers, bed mobility, and ambulation. She ambulated 150 feet with a hemi-walker with improved balance and gait. The recommendation of the therapist was home with family support and home physical therapy. The patient was medically stable with no evidence of need for supervision by acute PMR or acute rehab nursing care. She may benefit from further PT but does not require an intensive therapy program. IRF admission is not medically necessary as she is at high functional level.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-approveTrulicity injections 1.5/0.5 for the "beneficiary" .You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication falls under Part D coverage, but the enrollee has no pharmacy 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 Plandoes not haveto pre-approveTrulicity injections 1.5/0.5 for the "beneficiary".
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ararnesp.You asked the Plan to pre-approve Aranesp. You say that this is necessary.The Plan denied your request. The Plan says that this is not covered if you have any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, hemolysis, bleeding, or bone marrow fibrosis.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 Aranesp. Our reviewer says that Aranesp is medically reasonable and necessary in this case. Although erythropoetic agents such as Aranesp are generally not used in the treatment of myelofibrosis there aresome patients that have a response. You also have chronic renal insufficiency, grade IV, which is why you respond to Aranesp and this would be a covered indication. Our physician reviewer found you meet criteria for coverage of Aranesp.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have been met.Therefore, we decided that the Plan has to pre-approve Ararnesp.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/orsend 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leuko Vantage Next Generation Sequencing genetic testing panel for the enrollee.
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says this test has not been cleared or approved by the FDA.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 panel. Our reviewer says that the requested panel is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a diagnosis of CMML, for which treatment has not currently been recommended. While claimed in the appeal letter, there is no documentation to support that the requested genetic testing will in any way alter the enrollee's diagnosis or treatment plan. Therefore, the documentation does not support that the requested testing is currently medically necessary and reasonable. 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve Leuko Vantage Next Generation Sequencing genetic testing panel for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a Vertiflex interspinous and/or interlaminar device.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of this health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 denyingthe request to pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental, and more research is 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 the device have not been met.Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injection services.
You asked the Plan to pre-approve the Synvisc-One injection services. You say that The Plan denied your request. The Plan says the records do not show that the enrollee has had previous treatment with or has contraindication 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 services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation provided does not show that the enrollee has trialed viscosupplemental treatments Orthovisc and Monovisc. Our physician reviewer found that the documentation does not outline contraindications or reasons 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 Synvisc-One injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injection 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 enrollee would be best served in an IRF program.
The Plan denied your request. The Plan says the enrollee's medical condition is stable and she does not have
complex rehabilitation 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee suffered a pontine stroke on 12/17/2019 with associated right
hemiparesis, dysphagia, and spatial deficits. The complexity of the patient'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 1/3/19 document indicates a functional decline and follow up labs, chest x-ray and head CT
ordered. It is not appropriate to transfer the patient to a rehabilitation facility given the patient's recent
functional decline and additional medical work up pending. The documentation does not reveal that the patient
requires or can tolerate the intensity of an IRF stay with close physician or nursing supervision. The patient
may benefit and participate in additional therapy in the future of PT and OT but the patient does not require this
on an intensive rehabilitation facility therapy program level in an IRF 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 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 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 the enrollee does not require a physician to assess him at least three times a week, and the enrollee does not require specialized treatment or 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve the home health services to be provided by out of network (OON) agency.You asked the Plan to pre-approve the OON home health services. You say that you need physical therapy in the home setting and you have used this provider in the past.The Plan denied your request. The Plan says you had been approved for this OON provider previously but ended in October 2019. There are other in-network home health agencies that can provide the care you require.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 is not a network provider 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 haveto pre-approve the home health services to be provided by out of network (OON) agency.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick.You asked the Plan to pre-approve self-administered drugs. You say that you have been on this drug for several years.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 your 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-approve Enbrel Sureclick.Benefits for self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.