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 you require the IRF services The Plan denied your
request. The Plan says your needs can be met at an alternative 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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require physical
therapy and occupational therapy services but based on the medical records provided the patient does not
require an intensive inpatient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane and Gemcitabine with supporting drugs
Ondansetron and Dexamethasone.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says
Abraxane requires documented hypersensitivity reaction to paclitaxel or docetaxel, or a documented
contraindication to standard hypersensitivity to premedications.
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 requested services. Our physician
reviewer found that the enrollee has a diagnosis of malignant neoplasm of lower lobe, right bronchus or lung.
The Plan requires a trial of paclitaxel or docetaxel before they will approve the requested drug, Abraxane. The
case file does not contain documentation of trial and failure of Taxol (paclitaxel) or Taxotere (docetaxel). The
documentation does not support that Taxol or Taxotere would likely be less effective, 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve Abraxane and Gemcitabine with supporting drugs Ondansetron and
Dexamethasone.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that the authorization should be reconsidered and
approved. The Plan denied your request. The Plan says this is denied based on Medicare rules and personal
care needs.
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 admission. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for transfer
are not met.
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. 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 she 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery (23430, 29823, 29826, 29827).
You asked the Plan to pre-approve shoulder surgery. You say that the services are necessary. The Plan denied
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not
been met.
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 shoulder surgery. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no documentation of a trial and failure of conservative treatments for shoulder pain.
Surgery is not needed 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 shoulder surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve shoulder surgery (23430, 29823, 29826, 29827).
Appeal type: Surgery
Decision: Unfavorable

1. Patients must be clinically stable (e.g., not in shock, from any etiology);
2. LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic
Resonance Imaging (MRI), or catheter angiography;
3. Patients must not have:
-Significant, irreversible brain damage; or,
-Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of
survival less than one (1) year; or,
-Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
You can find this rule in National Coverage Determination (NCD) for Implantable Automatic Defibrillators
(20.4) - Effective February 15, 2018.
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 defibrillator. Our reviewer says that
the requested defibrillator is not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is an 86-year old male with persistent severely reduced LV ejection fraction in
spite of goal directed medical therapy. In this circumstance implantation of a defibrillator may be considered
appropriate but there is no covered indication for a biventricular device since there is no documented LBBB
and the QRS duration does not exceed 130msec (ECG reports only 110msec).
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 defibrillator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a biventricular implantable cardioverter defibrillator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says skilled nursing care, as defined by Medicare, is not required.
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 admission. Our reviewer says that
the requested admission is not considered medically reasonable and necessary in this case. Our physician
reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a step therapy exception for Entyvio intravenous
solution.
You asked the Plan to pre-approve Entyvio. You say that , considering the enrollee's history and condition, the
requested drug is warranted, appropriate, and medically necessary. The Plan denied your request. The Plan says
before the requested drug can be covered the enrollee must try Inflectra or Renflexis.
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 Entyvio. Our reviewer says that the
criteria for coverage of the requested drug have not been met. Our physician reviewer found meta-analysis of
biologic agents including vedolizumab and the TNF-inhibitors infliximab, adalimumab, and golimuma,
identified no conclusive evidence that any one was more effective than any other in maintaining clinical
remission in patients with inflammatory bowel disease (IBD). Further, specialty society guidelines identify no
advantage of induction therapy with Entyvio in biologically-naive IBD patients compared with Plan-preferred
infliximab. Our physician reviewer found that the medical record does not support absolute contraindication to
infliximab biosimilars to require Entyvio as a medically necessary plan policy exception.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve a step therapy exception for Entyvio intravenous solution.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 20, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this appeal reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
the member's primary care physician did not refer these services.
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 pay for 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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab work provided on March 20, 2020 by an out of
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee. 
 
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria. 
 
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 Rituxan. Our reviewer says that Rituxan is not medically reasonable and necessary for the enrollee in this case. There is no evidence that the enrollee has previously tried and not responded to a TNF antagonist or that she is going to take methotrexate with the requested drug. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Rituxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood pressure monitor (A4670).You asked the Plan to pre-approve blood pressure monitor. You say that the claim should be paid.The Plan denied your request. The Plan says the blood pressure is well controlled, therefore the claim is denied.The Plan follows Medicare rules. Medicare rules say that the enrollee's must have white coat hypertension or masked hypertension to meet coverage criteria.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 blood pressure monitor. Our reviewer says that the service is not medically necessary. Our physician reviewer found documentation notes the enrollee has a diagnosis of essential hypertension and treated with Metoprolol. Review of the records do not support suspicion of white coat hypertension or masked hypertension. The enrollee has had the diagnosis of essential hypertension, is treated with medication and has received diet counseling. Documentation does not support the national guidelines are 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 blood pressure monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve blood pressure monitor (A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing mattress.
You asked the Plan to pre-approve a powered pressure reducing mattress. You say that the requested powered
pressure reducing mattress is medically necessary. The Plan denied your request. The Plan says the enrollee
does not meet criteria for the requested powered pressure reducing mattress.
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 a powered pressure reducing mattress.
Our reviewer says that the enrollee does not meet criteria for the requested powered pressure reducing mattress.
Our physician reviewer found based on the documentation provided, the enrollee is noted to have T5 paraplegia
and to use a wheelchair. There is no documentation as to why the enrollee requires a medical mattress, or what
type of medical mattress she requires. The documentation does not support that the requested equipment is
medically necessary or 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 a powered pressure reducing mattress have not been met. Therefore, we decided
that the Plan does not have to pre-approve a powered pressure reducing mattress.
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 request exceeds your 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation, HHS). 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: 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 requested IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested IRF admission.
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 enrollee does not meet criteria for the requested IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to currently perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's 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 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.