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

We decided that the Plan does not have to pre-approve polysomnography (95811).You asked the Plan to pre-approve the polysomnography. You say that the member requires a repeat sleep study in order to get a new CPAP device. The Plandenied your request. The Plan says there is no requirement for a new sleep test or trial period.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 polysomnography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no rationale for an attended split night sleep study, versus a home sleep study was submitted.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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (95811).
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 LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 in this case. Our physician reviewer found Based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital. Admitted for a stroke, the enrollee subsequently underwent definitive treatment of elbow injuries suffered the month before.The enrollee is currently receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and acute care hospitals 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee lives in an apartment at a senior living community. You say that it is not safe for her to return home. You say that the enrollee needs rehab to get as close as possible to her prior level of function. You say that the enrollee's physical therapist also recommended a SNF. The Plan denied your request. The Plan says a SNF admission is not supported based on the records provided.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute case with Atypical Measles Syndrome changes. The enrollee's prior level of function was living alone in a senior living community and her family helping when needed. The enrollee was modified independent with mobility and activities of daily living. The enrollee's current level of function is ambulating 120 feet with a rolling walker with standby assist/supervision and with standby assist/supervision with bed mobility and transfers. The records do not support that the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled complex nursing needs. The enrollee is ambulating household distances and requires little assistance with mobility and transfers. While the enrollee may benefit from continuing physical therapy and occupational therapy, the records do not support the need for daily therapy.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for transfer. You say that the enrollee requires prolonged hospitalization and the intensive skilled services that are offered at LTACH. The Plan denied your request. The Plan says transfer to an LTACH would add no additional services. The plan says that, with additional time in the current facility, clinical stability can be assured. The plan says that transfer to the next appropriate lower level of care such as skilled nursing facility or acute rehab can then be determined.
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) having been treated non-operatively for a perforated appendix. The enrollee is not intubated/ventilated. The enrollee is being allowed to take orals. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 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-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health services.
You asked the Plan to pre-approve the continued home health services. You say that you feel that you need this care. The Plan denied your request. The Plan says that the documentation does not show that continued visits are needed. The plan has approved 30 days to allow for education to be given to caretakers.
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing coverage of home care services. There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services at issue in this appeal. Although the plan has decided to extend coverage for a short time, without a NOMNC being issued, there is no valid denial notice which must be issued for this to be enforced. Therefore, we decided that the Plan has to pre-approve continued home health 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.
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically necessary. The Plan denied your request. The Plan says all of services that would be provided in the LTACH are already being provided in the current acute care setting. The plan says that the requested LTACH services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted or a continuation of peritoneal dialysis on January 24, 2020. The enrollee was diagnosed with pneumonia and metabolic encephalopathy which is being managed. The enrollee is not required to discharge elsewhere to receive ongoing acute level care. The enrollee requires monitoring and management of kidneys (peritoneal dialysis), monitoring of blood sugars, continuous positive airway pressure at night (CPAP), monitoring of lungs, respiratory treatments, IV antibiotic, monitoring of blood pressure, pain management, special diet, frequent labs and doctor's visits, and physical therapy, which ca be safely managed in the enrollee's current care setting. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH which are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve the Trulicity. You say that the enrollee has been tried on Ozempic and Januvia. You say that the enrollee has been receiving samples of Trulicity and taking it alone. You say that her A1c has decreased and her blood sugar levels have improved. The Plan denied your request. The Plan says the requested medication is a benefit exclusion. The plan says that the Medicare Advantage plan does not cover prescription drugs.
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 Trulicity.
Benefits for the Trulicity 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: 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 IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment in an intensive rehabilitation therapy program. Basedon the medicalrecords provided there is concern that the enrollee may not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.Medicare coverage criteria are not 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitationfacility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN) services.
You asked the Plan to pre-approve the IDPN services. You say that this provider specializes in this type of nutrition which is medically necessary for the dialysis patient. The Plan denied your request. The Plan says Medicare does not cover nutrition for enrollees with functioning gastrointestinal systems whose deficiencies are caused by dialysis treatment.
Medicare only covers IDPN when the documentation clearly shows that it is needed due to non-function of the GI tract. The Plan follows this same rule. There is no documentation of non-function of the GI tract. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN) 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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria 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 based on the medical records provided the complexity of the nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Based on the medical records provided treatment does not require an intensive 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.You asked the Planto pre-approve the additional physical therapy. You say that you did not receive a home exercise program that replicates physical therapy. The Plan denied your request. The Plan says the additional physical therapy is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you should not require an additional 12 sessions of a professional therapist to safely and effectively provide treatment. The services do not need to be performed only by a therapist, or under the supervision of a therapist. You should be competent and able to transition toan independent 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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDoxycycline hyclate 100mg capsules for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says this plan does not have a Part D benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDoxycycline hyclate 100mg capsules for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of excessive skin.
You asked the Plan to pre-approve removal of excessive skin. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 removal of excessive skin. Our reviewer says that Medicare coverage criteria are not met. Our reviewer found based on the medical documentation provided the requesting surgeon has not adequately documented typical functional impairment associated with excess skin and fat of the thighs and excess fat of the back and flanks. The enrollee states some functional concerns with her excess, but this is not supported by the medical documentation. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Thus, as the documentation does not support that a typical functional impairment exists related to her documented excess soft tissue of the thighs, backs and flanks (and has failed reasonable conservative management), Medicare coverage criteria are not 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 removal of excessive skin have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of excessive skin.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits
You asked the Plan to pre-approve the physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this care. Therefore, coverage criteria has not been met.
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 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-approve physical therapy visits
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 the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.ThePlan 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 fileand 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was initially admitted to acute care hospital on 1/08/2020 for acute hypoxic respiratory failure secondary to community acquired pneumonia. The enrollee has a history of chronic obstructive pulmonary disease, sleep apnea, atrial fibrillation, congestive heart failure, diabetes, chronic kidney disease, deep vein thrombosis and morbid obesity. He has been treated in hospital with intravenous diuresis and antibiotics; he has required intubation and mechanical ventilation due to respiratory failure and now has a tracheostomy. He also has a percutaneous feeding tube and he has required intermittent hemodialysis for acute kidney injury. He has a thoracic aortic dissection. The enrollee is being followed by vascular surgery. He has a PICC line. Physical and occupational therapy are working with the enrollee also. Based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires.  The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. The enrollee is getting these services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to 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 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.