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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
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 for respiratory failure, heart failure, dehydration and poorly controlled diabetes. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed 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 Plan does not have to pre-approve admission 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-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 SNF admission can be covered to provide additional appropriate treatment.
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 fifteen hours per week of rehabilitative services. The enrollee is able to ambulate, but he is currently being activity restricted due to his post-op pulmonary emboli. 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).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the patient has tried and failed the required drugs - Orthovisc and Monovisc. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CPAP supplies to be provided by out of network provider.You asked the Plan to pre-approve CPAP supplies. You say that you are not happy with the in-network provider.The Plan denied your request. The Plan says medical information does not support the need for an authorization to a non-plan provider.Medicare rules say that planscan require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe CPAP supplies to be provided by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approv skilled nursing facility (SNF) admission.You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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 ADLs 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740), and core buildup (D2950) for tooth # 13.
You asked the Plan to pre-approve the dental services. You say that your tooth is bothering you. You say that your tooth is so decayed and mostly a filling. You also say that the crown cannot be done without the post and core. The Plan denied your request. The Plan says the crown for tooth # 13 does not meet the criteria for coverage. The Plan also says that core build up is not listed as a covered service in the office reference manual.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the provided x-ray reveals a two surface existing restoration on tooth # 13. In this instance there is no clear damage to either cusp, and only a two surface restoration seen. The documentation shows there are not enough surface damage, as there are only two involved surfaces seen and no indication that a cusp has been compromised the criteria for crown restorations has not been met. The reviewer also found that since core buildup is a service predicated on its use to support a crown, and being secondary to the primary service is not medically necessary when the primary service is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740), and core buildup (D2950) for tooth # 13.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a Ramucirumab, Gemcitabine, Carboplatin, Dexamethasone, Palonsetron, and Ondansetron drug regimen for the enrollee.You asked the Planto pre-approvethe drug regimen. You say that this is medically necessary.The Plandenied your request. The Plansaysthe off label use of these drugs for this condition is not medically accepted.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 the drug regimen. Our reviewer says that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found this reviewrelates to a request for Ramucirumab to be given in combination with Carboplatin and Gemcitabine with anti-emetics for stage IIIB poorly differentiated squamous cancer of the lung. The use of Ramucirumab in combination with Carboplatin and Gemcitabine is not FDA approved nor is it included as recommended in any of the Medicare approved compendia. The documentation does not support that the drug regimen is safe and effective for the enrollee.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 drug regimen have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Ramucirumab, Gemcitabine, Carboplatin, Dexamethasone, Palonsetron, and Ondansetron drug regimen 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 you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not need 3 hours a day of therapy and his medical illnesses are stable.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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the member is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. There is no evidence of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system along with an expandable controller with related hardware.
You asked the Plan to pre-approve the power seat elevation system and expandable controller. You say that the requested components should be approved. The Plan denied your request. The Plan says a power seating system is not covered by Medicare. In addition, there is no medical need for the expandable controller.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that power seat elevation systems are not primarily medical in nature and cannot be 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 power seat elevation system and expandable controller. Our reviewer says that the expandable controller is not considered medically reasonable and necessary in this case. Our physician reviewer found the electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) are not medically necessary. The documentation reveals the patient's upper extremity strength and ability to perform ADLS should be sufficient to control the power options with their own switches which were included already in the approved wheelchair power options. We looked at this physician's review, the file, and Medicare rules. Though a power seat elevation system may be useful, it is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system and expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system along with an expandable controller with related hardware.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve treatment with onabotulinumtoxina (J0585).You asked the Plan to pre-approve onabotulinumtoxina. You say that onabotulinumtoxina is medically necessary.The Plan denied your request. The Plan says that onabotulinumtoxina is not medically necessary.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 onabotulinumtoxina. Our reviewer says that onabotulinumtoxina is medically necessary at this time. Our physician reviewer found the Medicare-approved compendium Micromedex does contain citations to support onabotulinumtoxina as medically reasonable and necessary for Parkinson's Disease and inability to tolerate excess salivary secretions. Onabotulinumtoxina is supported as safe and effective 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 onabotulinumtoxina have been met.Therefore, we decided that the Plan has to pre-approvetreatment with onabotulinumtoxina (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says the current request exceeds the limitations of coverage.
The Plan must follow Medicare rules. Medicare rules say that two RFA sessions can be covered every 12
months.
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 injection. Our reviewer says that the
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer
found the request exceeds the utilization criteria, and is therefore deemed not medically necessary. The enrollee
has chronic neck pain, and had two sessions of RFA treatment in 2019. The request is for another RFA session
within 12 months of the first two sessions.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) 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 [you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says IRF admission 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member'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 member required the intensity of an IRF stay with close physician or nursing supervision. The member's functional status does not require 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-approve acute inpatient rehabilitation facility (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) for the enrollee.You asked the Plan to pre-approvethe admission. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 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-approveadmission to a skilled nursing facility (SNF) 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).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says SNF 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 above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating
household distances and tending to ADLs 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 (ex. home,
AL, LTC).
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).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveLyrica capsules.You asked the Planto pre-approvethe Lyrica. You say that this medication is medically necessary.The Plandenied your request. The Plansaysthis is an oral drug which is not covered by Medicare Part B. Part D coverage must be requested.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveLyrica capsules.Benefits for the Lyricamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.