Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued monitoring, and daily physician visits. The Plan denied your request. The Plan says the enrollee's current needs are being met in the current setting.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for an abdominal gunshot wound. The enrollee is receiving antibiotics and wound care. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: 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 is ready to be discharged. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of care, 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 the enrollee's medical conditions appear stable. The enrollee is able to perform bed mobility and transfers without hands-on assistance and is ambulating limited distances with minimal assistance. She does not require an intensive therapy program. The enrollee is limited by pain and debility after her recent surgery and associated complications. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysall services that would be provided in the LTACH are being provided safely in the current health care setting which is approved by the health plan.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following a period of prolonged hypoxia resulting in anoxic brain injury. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee does not appear to be appropriate for ventilator weaning and is noted to have an exceedingly poor prognosis. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs arelicensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosisand 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for cholecystitis. The enrollee underwent surgery, which was later complicated by pancreatitis and renal failure. The enrollee continues to have pain and a poor appetite. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveZARXIO (filgrastim-sndz) injections.You asked the Planto pre-approvethe ZARXIO injections. You say that this is necessary to treat the enrollee's neutropenia.The Plandenied your request. The Plansaysthe treatment of neutropenia is necessary; however, there is no evidence that the plan preferred medications would not be effective.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 ZARXIOinjections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of lower-outer quadrant of right female breast. The drug is requested for neutropenia after chemotherapy. There is no documentation of trial and failure of Neupogen or NIVESTYM. The documentation does not support that the biosimilars, Neupogen (Filgrastim) or NIVESTYM (filgrastim-aafi) 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 the ZARXIO injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveZARXIO (filgrastim-sndz) injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography of the lower extremity (73701).You asked the Plan to pre-approvecomputed tomography of the lower extremity.You say that a CT scan of the lower extremity is medically necessaryfor the enrollee as she has developed lymphedemaof her left lower extremity that has caused swelling, tightness,heaviness, and poor range of motion;which has severely limited her quality of life.The Plan denied your request. The Plan says that it is unreasonable and redundant to repeat the CT scan from February 2020, and this testing would not provide additional and medically necessary information to affect the enrollee's treatment plan.The Plan must follow Medicare rules. Medicare rules say that CT 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 computed tomography of the lower extremity. Our reviewer says that the enrollee does not meet criteria for coverage of computed tomography of the lower extremity. Our physician reviewer found the enrollee has chronic left leg lymphedema and is scheduled for surgical lymph node transfer. Documentation supports that the enrollee is approved for a CT angiogram of the pelvis. The enrolleeunderwent a CT scan of the extremity on February 17, 2020. The documentation does not discuss the results of this study or indications for a similar test. Without additional supporting documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computed tomography of the lower extremity have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography of the lower extremity (73701).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that you had a recent surgery and need a higher level of intensity with your therapy.The Plandenied your request. The Plansaysyou are medically stable and do not require three daily hours of intensive therapy. Criteria for IRF care are not met.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 was admitted after a fall causing a sacral fracture. She initially had urinary retention requiring catheterization. She recently had a knee replacement and was restricting to toe-touch weight bearing on the left leg and weight bearingas tolerated on the right. She was receiving home care prior to this admission.Based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable as described above with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her medical stability and lack of complexity 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that it is felt that IRF care is necessary.The Plan denied your request. The Plan says the criteria for IRF care are not met.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 requestto 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 patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this or appear 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee's best chance of recovery lies within an LTACH.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pressure sores. The enrollee has received wound debridement. Theenrollee continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton therapy for the enrollee.You asked the Plan to pre-approveproton therapy. You say that proton therapy offers the enrollee a better quality of life.The Plan denied your request. The Plan says no data shows that proton therapy is superior to Intensity-modulated radiation therapy (IMR)T for prostate cancer treatment.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 proton therapy. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy.Clinical trials are necessary to establish a possible advantage of this expensive therapy. Any potential benefit or detriment of proton therapy over standard IMRT is investigational. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT or Image-guided radiation therapy (IGRT). Therefore, the requested services are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton therapy have not been met. Therefore, we decided that the Plan does not have to pre-approveproton therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs daily physician involvement, nursing, and rehab therapy to optimize recovery.The Plan denied your request. The Plan says the enrollee has reached the 90-day benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up 90 days per benefit period and 60 extra lifetime reserve days over your lifetime for inpatient days.We looked at the file, and Medicare rules. The file shows that the enrollee has exhausted all of his daysduring this benefit period. Although the enrollee may still need inpatientcare, the Plan is not required to pay for more than 90days of inpatientcoverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you are currently in acute care and would benefit from LTACH care.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that it is not medically necessary to transfer the enrollee to an LTACH and that continued management can be provided at the skilled nursing facility level once the acute level of care is no longer 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 enrollee is currently undergoing treatment at an acute care hospital (ACH). Initially admitted with rapid rate atrial fibrillation, the enrollee suffered two cardiac arrests and was found to have had a stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee appears to be tolerating ventilator weaning, but is noted to have a poor long-term prognosis. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you need physical therapy to be mobile again.The Plan denied your request. The Plan says there are no medical issues that require supervision by an inpatient rehab physician.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 you are independent with ambulation, at maximum assist with sitting to standing, and have decreased left shoulder range of motion. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status required the intensity of an IRF stay with close physician or nursing supervision. Youmay benefit and participate in additional physical and occupational therapy, but you do not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based onthis 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.