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

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond January 3, 2020.You asked the Plan to pre-approvethese services. You say that you need more therapy.The Plan denied your request. The Plan says the continued services are 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on December 24, 2019 after hospitalization for spinal fractures. You need assistance with bed mobility and transfers and walking 75 feet with a walker. You need varied assistance for activities of daily living. You have no skilled nursing needs or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond January 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the beneficiary.You asked the Plan to pre-approveIRF care. You say that the enrollee needs intensive therapy to build up her strength and the ability to walk on her own.The Plan denied your request. The Plan says the enrollee does not require a multidisciplinary approach with specialized therapies.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 the enrollee is at contact guard assist for ambulating, cues, and sequencing. She demonstrated increased standing tolerance for activities of daily living. 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 documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but her functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the beneficiary.
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 requires a comprehensive team to ensure proper management of his condition, and reduce the risk of readmission to acute hospital.The Plan denied your request. The Plan says the enrollee does not need an intensive program, or require close physician supervision.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 the enrollee's current level of function is moderate assist for basic activities of daily living and dressing. he is at supervision for ambulation, and minimal assist for bed mobility and transfers. 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 documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but his functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules 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 skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that you cannot get out of bed, or go to the restroom without assistance.The Plan denied your request. The Plan says you do not require complex daily skilled nursing or rehab therapy.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 services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at supervision to contact guard assist with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomographic angiography of the chest (CTA).
You asked the Plan to pre-approve the CTA. You say that the clinical information supports the need for the requested CTA to be provided in a tertiary facility. The Plan denied your request. The Plan says that the CTA of the chest can be provided at an equally qualified in-network provider.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that the CTA at that medical center is considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports coverage of the CT angiogram at the tertiary facility. Our physician reviewer found that the enrollee has a unique condition necessitating tertiary level treatment and, just as importantly, tertiary level regular follow-up. Our physician reviewer found that the enrollee has a pseudoaneurysm in the ascending aorta that has undergone embolization but may be increasing in size. Our physician reviewer found that the enrollee also has evidence of thoracic aortic aneurysm and history of dissection. Our physician reviewer found that follow-up of this requires specialized imaging in the center where the provider practices. Our physician reviewer found that this is important for proper follow-up and decision making as well as good patient 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 CTA have been met. Therefore, we decided that the Plan has to pre-approve a computed tomographic angiography of the chest (CTA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implanted testosterone pellets, 75mg.
You asked the Plan to pre-approve the implanted testosterone. You say that the implanted testosterone pellets are medically necessary. The Plan denied your request. The Plan says 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 the implanted testosterone. Our reviewer says that the implanted testosterone pellets are not medically necessary at this time. Our physician reviewer found the enrollee has mild symptoms and notes a list of denied symptoms related to hypogonadism. The documentation does not include laboratory testosterone levels before or after previous implantation of the pellets nor does it include the effect on symptoms. The FDA supports testosterone replacement when hypogonadism is caused by a condition of the testicles, pituitary gland, or brain. The documentation does not support any of these conditions. 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 implanted testosterone have not been met. Therefore, we decided that the Plan does not have to pre-approve implanted testosterone pellets, 75mg.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 issuein 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 medical services to be provided.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc injections (J7324).
You asked the Plan to pre-approve the Orthovisc injections. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of Orthovisc.
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 Orthovisc injections. Our reviewer says that you meet Medicare criteria for coverage of Orthovisc injections. Our physician reviewer found that you had significant functional limitations in activities of daily living. X-ray findings showed mild left knee osteoarthritis. Conservative treatment had included activity modification, bracing, ice, heat, exercise, and corticosteroid injection without sustained improvement. Evidence based medical literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A trial of Orthovisc injections is reasonably indicated for treatment of your knee pain given the failure of reasonable conservative treatment, persistent pain and functional limitations, and to avoid surgical treatment. Therefore, the documentation supports that Orthovisc injections are medically reasonable and necessary and safe and effective for the treatment of the left knee osteoarthritis. 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 Orthovisc injections have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc injections (J7324).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRituximab.You asked the Plan to pre-approveRituximab. The Plan denied your request. The Plan says this drug 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 Rituximab. Our reviewer says that Rituximab is not medically reasonable and necessary. Our physician reviewer found that the enrollee has a diagnosis of autoimmuneencephalitis. The use of Rituximab is not FDA approved for this diagnosis. Additionally, approved compendia do not support this use. Without the support of the literature, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab have not been met.Therefore, we decided that the Plan does not have to pre-approveRituximab.
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). 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 needs can be safely met at a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following scheduled removal of her gallbladder. Post-operatively, the enrollee has had issues with hypercarbia/respiratory failure. The enrollee is currently being managed with BiPAP. 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 Plandoes not haveto pre-approve admission to a long term acute care hospital (LTACH).
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 care can be received in another setting, such as home, a long-term care facility, or other outpatient 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-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implants, tissue regeneration, and frenuloplasty.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan saysthis is not a covered benefit.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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The plan covers only those dental services listed in the Evidence of Coverage. Dental implants, tissue regeneration, and frenuloplastyare not listed, and therefore are not covered.Therefore, we decided that the Plan does not have to pre-approvedental implants, tissue regeneration, and frenuloplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtandi 40mg capsule.You asked the Plan to pre-approve the drug. You say that this should be paid for.The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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 Xtandi 40mg capsule.
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 SNF admission. You say that the enrollee would benefit from rehab in the SNF setting.The Plan denied your request. The Plan says there is no need for daily skilled therapy in this case.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 93 year old woman with dementia, asthma and lung cancer who was admitted to the acute hospital on 12/25 due to left femur fracture with subsequent hemiarthroplasty. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT in the acute hospital. The beneficiary was at a contact guard to minimal assist level with functional mobility including gait to short distances with a rolling walker. The beneficiary had poor safety awareness and required multiple cues.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, skilled therapy is not required on a daily basis. This beneficiary 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 SNF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve specialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available to the enrollee.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 the medical services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewheelchair accessory transit system or kit (K0108)You asked the Plan to pre-approvetransit option for wheelchair. You say that the request reconsideration for the denial of the transit option as this is not a request for comfort, but rather is a medical and legal necessity.The Plan denied your request. The Plan says this item is aconvenience item and not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvewheelchair accessory transit system or kit (K0108)