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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 83-year-old male with a past medical history of diabetes, hypertension and chronic lymphocytic leukemia who was admitted to an acute inpatient rehabilitation facility on April 27, 2021, after a stroke. Based on the medical records provided this patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. However, there is no documentation that the patient requires skilled nursing services. In addition, daily skilled services are not required. Services in the home with home health or in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve a CardioMEMS device. You say that the requested service is medically necessary for the enrollee. The Plan denied your request. The Plan says that this device is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has NYHA Class III heart failure. He is on maximally tolerated guideline directed therapy and his systolic blood pressure is near 100. In this case, the management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in recent acute hospitalization. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage complex diuretic and vasodilator regimens. Given the ongoing symptoms which appear very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. In addition, the CMS applicable rule requires device safety, medical necessity and reasonableness and does not require participation in a clinical trial for the appropriate clinical use of this device, if the patient meets the published medical necessity indications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of age-related osteoporosis without current pathological fracture. The Plan requires a trial of Zoledronic Acid or a history of osteoporotic fracture before they will approve the requested drug. The enrollee does not have a new fracture and has not tried and failed Zoledronic Acid. In addition, 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.
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 60 mg/ml syringe.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that the
requested admission to a SNF is not medically necessary. Our physician reviewer found that you are a 79-year old
female with a past medical history of diabetes and hypertension who has been in an acute inpatient
rehabilitation facility since April 27, 2021, after suffering a stroke. In this case, you do require skilled therapy
services and also requires skilled nursing services. Furthermore, these services are required on a daily basis.
However, based on the medical records provided you do not require the services on an inpatient basis, only in a
skilled nursing facility setting. Continued services in the acute inpatient rehabilitation facility appear
appropriate in this case until you are stable to transfer to a lower level of care such as home with home health
or to a long-term care facility.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 disagree with the denial. 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 in the Medicare rules section. 

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 medically necessary. Our physician reviewer found the enrollee had prior cervical spine surgery after a fall and went to a skilled nursing facility. He was discharged to the assisted living facility on November 20, 2020. He has ongoing weakness but is medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS procedure (CPT code(s): 33289 and C2624), for the enrollee.

You asked the Plan to pre-approve the procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the Class III symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational in this situation and meets the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule. 

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS procedure (CPT code(s): 33289 and C2624), 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality 120 mg/mL injection.
You asked the Plan to pre-approve Emgality. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the 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 Emgality 120 mg/mL injection.
Benefits for Emgality 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services after May 6, 2021.

You asked the Plan to pre-approve continuation of SNF services after May 6, 2021. You say that you cannot be discharged until you are tested for COVID-19. The Plan denied your request. The Plan says you no longer need skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continuation of SNF services after May 6, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of May 6, 2021 the member did not require any skilled nursing or rehab services on a daily basis. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of May 6, 2021. The member received skilled care and improved, however his function had plateaued, and he did not require any further inpatient skilled rehab services. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of May 6, 2021, the member required custodial services. The denial for further inpatient skilled care is upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services after May 6, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services after May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 they are currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services that are not available at the acute care hospital. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep apnea oral appliance.
You asked the Plan to pre-approve the oral appliance. You say that the enrollee does have out of network benefits, and this device is medically necessary for treatment of sleep apnea. The Plan denied your request. The Plan says this cannot be approved from a provider who is not enrolled in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that no payment can be made to a provider who is not enrolled in the Medicare program. We have reviewed Medicare databases and have not been able to find evidence of the requested provider's enrollment with Medicare. As such, we find that the coverage rules for the requested item are not met. Therefore, we decided that the Plan does not have to pre-approve a sleep apnea oral appliance.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an infected hematoma of the right thigh. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 in the Medicare rules section 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any parental medications or complex wound care. You have plateaued and you do not require any further inpatient skilled rehab services. The documentation shows that you do have a feeding tube but there are no documented complications involving care. The documentation does not support that you require skilled nursing services or skilled therapy services on a daily basis. Your care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tolvaptan 15MG Tablet (CPT code J8499), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the medication is not covered by Medicare Part B and has no Part D coverage.
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 Tolvaptan 15MG Tablet (CPT code J8499), for the enrollee.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.