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

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are the appropriate level of care for the enrollee. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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 Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One syringe (J7325).

You asked the Plan to pre-approve Synvisc-One syringe (J7325). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says he enrollee has not first tried and had a contraindication or intolerance to Monovisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One syringe (J7325). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug. Based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One syringe (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One syringe (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Tysabri after a 6-month period.

You asked the Plan to pre-approve Tysabri. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Tysabri is correct, because there must be a 6-month review to allow reassessment for the absence of unacceptable toxicity from the drug and to ascertain monitoring of the response to therapy indicating a beneficial response. The Plan also says that they have approved use of Tysabri up to a period, so at this time the denial is only for continuation of Tysabri after this approved period.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Tysabri. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Tysabri after the Plan-approved period. Our physician reviewer found the requested use of Tysabri is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Its use in this case is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tysabri have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Tysabri after a 6-month period.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies, the patient's functional level does not require this therapy or appear to tolerate this therapy in 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to zoledronic acid. Based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. Based on the medical records provided there is no documentation that the enrollee has a history of an osteoporosis related fracture.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia (J0897). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the patient has not tried and failed the required drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial for the enrollee.
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented diagnosis that is an indication for this trial.
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 trial. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have an evidence-based indication for this stimulator. The request is not medically reasonable or necessary. 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 trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says medical records were not received to support the requested injection.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. As medical records were not received, it was not able to be determined if step therapy guidelines were followed. 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 a Botox injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on August 15, 2020, through August 16, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the documentation submitted does not include the amount of time spent providing the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on August 15, 2020, through August 16, 2020.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee was hospitalized with acute hypoxic respiratory failure due to pneumonia and pulmonary edema requiring intubation. Additionally, the enrollee had spontaneous atrial fibrillation with rapid ventricular response which spontaneously converted to sinus rhythm. A tracheostomy and PEG-tube were placed. The tracheostomy has been replaced due to bleeding at the site. The enrollee remains drowsy and not able to follow commands off sedation. The enrollee is euvolemic and an invasive coronary angiogram was provided and found to be unremarkable. Computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain did not show any acute changes. The enrollee's prior level of function was independent with household mobility. Per the therapy assessment, the enrollee is unable to participate in therapies as reported to not open her eyes or interact and there was no resistance or indication of discomfort for bilateral upper extremity joints passive range of motion. The enrollee has not required prolonged mechanical ventilation as she has been tolerating the trach collar with good oxygen saturation. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a transfer to the LTACH level of care is medically necessary for continuation of care. You say the enrollee has complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says there is no evidence that treatment would be required at the LTACH level of care due to clinical complexity. The current care plan could be provided at an alternate level of care, such as a skilled nursing facility (SNF).
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 that this enrollee was admitted to the hospital with injuries after a motor vehicle collision. As of the Physical Medicine and Rehabilitation progress note on March 4, 2021, the member remains in a Miami J collar, requires total assistance with lower body dressing, functional transfers with maximal assistance x 2, bed mobility with maximal assistance and ambulation has not been tested yet.
There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve vitamin and metabolic function assay services provided to the enrollee on March 30, 2020.
You asked the Plan to pre-approve the services. You say that this should be covered by the plan. The Plan denied your request. The Plan says that a corrected claim was not received.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. The case is extremely vague on what part of the claim was done incorrectly. It is not stated what could be done by the provider to correct the claim. No medical records were provided. Therefore, we decided that the Plan has to pre-approve vitamin and metabolic function assay services provided to the enrollee on March 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that without daily physical therapy you will not be safe. The Plan denied your request. The Plan says rules for pre-approval have not been met.
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 that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic office visit services received on July 22, 2020.
You asked the Plan to pay for the services. You say that you were advised it would be best to see a chiropractor. The Plan denied your request. The Plan says chiropractic services are only covered for manual manipulation of the spine to correct subluxation
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic office visit services received on July 22, 2020.
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 need rehabilitation to become mobile again. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. While you may benefit from and participate in multiple therapies, your functional level does not require this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays (D0210) and an unspecified dental procedure (D1999) provided September 23, 2020 to September 30, 2020.
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The Plan denied your request. The Plan says the denied procedures are not a covered benefit under your dental plan.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0210) and an unspecified dental procedure (D1999) provided September 23, 2020 to September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (arformoterol)for the enrollee.
You asked the Plan to pre-approve Brovana (arformoterol). You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of nebulizer. 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 Brovana (arformoterol). Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Brovana (arformoterol) is medically reasonable and necessary for enrollees when being used with another long-acting beta agonist. 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 Brovana (arformoterol) have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (arformoterol)for the enrollee.