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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for
continued SNF care.
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 continued SNF care. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found based on the documentation
provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented
skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living
with minimal supervision. Daily skilled services are not required to establish a maintenance program or to
prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a
practical matter, can be provided 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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lysis of epidural adhesions (epidurolysis).
You asked the Plan to pre-approve the epidurolysis procedure. You say that this procedure has been done in the
past and was helpful and should not be denied now. The Plan denied your request. The Plan says this type of
treatment is considered experimental as there are not studies showing it is more beneficial than placebo.
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 epidurolysis procedure. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee is a 78 year old male with a history of low back pain and stiffness
with decreased mobility. The pain is described as sharp, aching, and burning and radiates into the right buttock
and right leg. The symptoms are relieved by rest, heat, and analgesics. The enrollee is s/p back surgery three
years ago. The pain management specialist has recommended an epidurolysis. The enrollee also had this
procedure done six months ago.
Epidurolysis (lysis of epidural adhesions) or Racz procedure, involves passage of a catheter (Racz catheter)
endoscopically or percutaneously under fluoroscopic guidance into the epidural space under general anesthetic
or conscious sedation. Various protocols for breaking up adhesions and reducing pain and inflammation have
been described. The evidence for lysis of epidural adhesions with or without endoscopy is limited to a small
number of randomized, controlled trials with methodological weaknesses, nearly all from the same center. This
evidence is insufficient to establish the safety and effectiveness of epidural lysis in comparison with placebo
and alternative procedures. Larger, high-quality, controlled studies from other research groups are needed to
corroborate the currently available trials. Thus, epidurolysis is not considered medically necessary, as there is
no proven efficacy. This procedure is considered to be investigational.
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 epidurolysis procedure have not been met. Therefore, we decided that the
Plan does not have to pre-approve lysis of epidural adhesions (epidurolysis).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP supplies.
You asked the Plan to pre-approve the CPAP supplies. You say that you have been having issues with your
CPAP headgear. You say that your gear comes undone and your mask does not stay on through the night. The
Plan denied your request. The Plan says the records show that a replacement mask or ancillary equipment
cannot be replaced sooner than every 6 months.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that information must be submitted to confirm that Medicare
coverage criteria have been met.
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 CPAP supplies. Our reviewer says
that the requested items are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has obstructive sleep apnea, on CPAP for years. The enrollee reports problems
with the headgear coming off during the night. There is no indication in the medical records that the headgear
is defective, or that there are problems with the many other supplies that have been requested before the
allowed 6-month interval. More information is needed to establish the medical necessity of these supplies
before the allowed 6-month replacement interval.
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 CPAP supplies have not been met. Therefore, we decided that the Plan does
not have to pre-approve CPAP supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Novolog or Medicare Part B drugs. You asked the Plan to pre-approvetier exceptions for Medicare Part B drugs. You say that this exception is financially necessary.The Plan denied your request. The Plan says Medicare does not allow tier exceptions for Medicare Part B drugs. The Plan must follow Medicare rules. The rules Plans must provide enrollees with clear contract language. Your Plan contract clearly states Medicare Part B drugs have a 20% coinsurance. There is no provision for tier exceptions for Medicare Part B drugs. Therefore, we decided that the Plan does not have to pre-approvea tier exception for Novolog or Medicare Part B drugs.
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 there is no indication that an intensive rehab program is required.
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. Your medical status does
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple
therapies such as physical and occupational therapy but the documentation does not support that you require
therapy on an 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee. 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's condition must be of a level of complexity that requires an intensive and
coordinated interdisciplinary approach, including physician visits at least three times weekly.
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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 enrollee wants to get back to walking again. The Plan denied your request. The Plan says the enrollee does not require the level of intensity of therapy, nor has complex medical problems requiring daily physician oversight.
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 suffered fractures of your proximal left tibia and fibula, and patella when you tripped and fell. You have deficits in pain, balance, and activity. You are medically stable and do not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While you are expected to benefit from continuing physical and occupational therapy, the documentation does not support a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.
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 needs help getting in and out of bed, needs thyroid monitoring, and needs extensive rehabilitation therapy. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's case needs can be met at a lower level of care such as skilled nursing 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 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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 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 require, or to currently be able to 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is needed to recover from surgery. The Plan denied your request. The Plan says you do not meet Medicare guidelines for an IRF.
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 based on the medical records provided, 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 you do not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.
You asked the Plan to pre-approve inpatient hospital services. You say that the enrollee has an extensive problem list. The Plan denied your request. The Plan says the enrollee was clinically stable.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. The file shows that an inpatient hospital admission was requested for June 29-30, 2020. 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 inpatient hospital services. Our physician reviewer found that the hospitalization does not qualify for inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The emergency room evaluation showed no acutely life/limb threatening condition(s). The enrollee could have been safely monitored on observation status, before deciding if two midnights of care would be medically necessary. As is, the enrollee was discharged having received only one midnight 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical records do not establish that the outpatient PT visits are reasonable and
necessary.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found in this case, there
is no indication that prior PT has served to provide sustained, significant improvement in function, and there is
no indication that residual deficits could not be addressed via a home exercise 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve outpatient physical therapy services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Furosemide tablets.
You asked the Plan to pre-approve the Furosemide. You say that the medication being requested is medically necessary and that, without it, the enrollee will go into heart failure. The Plan denied your request. The Plan says the enrollee does not have Part D coverage with the Plan. The Plan says that the drug being requested is not covered under Part A and B.
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 Furosemide tablets.
Benefits for the Furosemide 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab (J9271) and Axitinib (J8999).
You asked the Plan to pre-approve Pembrolizumab and Axitinib. You say that the requested medications 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 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 Pembrolizumab and Axitinib. Our
reviewer says that the medications are not medically necessary. Our physician reviewer found the requested
combination is not FDA approved. The requested regimen is supported by the NCCN compendium for clear
cell type renal cancer. Neither the compendium, nor the NCCN Guidelines Version 2.2020 Kidney Cancer page
1 of 2, indicates the combination is not indicated after prior drugs in the same class as Pembrolizumab.
However, there is insufficient information in the submitted documents to know whether the enrollee's cancer is
clear cell type. Therefore, the submitted documentation does not support that the combination is medically
reasonable and necessary nor that it is safe and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Pembrolizumab and Axitinib have not been met. Therefore, we decided that the
Plan does not have to pre-approve Pembrolizumab (J9271) and Axitinib (J8999).
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 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 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 skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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.