Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy visits.
You asked the Plan to pre-approve outpatient rehabilitation visits. You say that you need more visits because
you do not have much strength in your arm or leg, and you are limited in daily activities. The Plan denied your
request. The Plan says the denial of authorization for these services is correct, because the Plan has approved 8
additional visits and 7 more beyond this amount 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 outpatient rehabilitation visits. 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 the requested therapy is generally accepted as a
specific and effective therapy for your condition. Goals include restoring function and educating regarding a
home exercise program prior to transition to a home program. In this case, there is no indication that prior
therapy has served to provide sustained, significant improvement in pain and/or function and there is no
indication that residual deficits could not be addressed via a home exercise program. Therefore, this therapy is
deemed not medically 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 outpatient rehabilitation visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the upper left and lower right quadrants.
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says that the documentation submitted does not demonstrate evidence of significant bone loss (2.5+ mm from the cementoenamel junction) and/or radiographic root surface calculus on 4 or more teeth per quadrant that is required to qualify the enrollee for this procedure under this 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. The Plan covers the scalings and planings 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 scalings and planings. Our reviewer says that the service meets the criteria for coverage. Our physician reviewer found periodontal scaling and root planing (D4341) meets the criteria for coverage due to pathological periodontal pockets, bone loss and subgingival calculus present in the four quadrants. 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 scalings and planings have been met. Therefore, we decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the upper left and lower right quadrants.
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-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the enrollee would like a Synvisc-One injection, even though there have been other injections offered to her. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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. Our reviewer says that Synvisc does not meet coverage criteria. Our physician reviewer found the Plan requires that other forms of Hyaluronic Acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of Hyaluronic Acid. Our reviewer found that there is no evidence that the enrollee has tried and not responded to these other forms of Hyaluronic Acid injections. There is no documentation as to why these other forms of Hyaluronic Acid would not be expected to be safe and effective for the enrollee. Our physician reviewer also found that the requested Synvisc-One is not shown to be currently medically necessary and reasonable.
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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
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 are not able to get to a normal state. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were recently admitted to the hospital with pneumonia and heart failure. You are now hemodynamically stable and do not have a fever. There is no worsening of oxygen needs. You need modified assistance with mobility and transfers. The complexity of your medical, nursing, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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 continued 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 the records do not show a need for treatment for an illness or injury.
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. There are no 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve the seat lift. You say that you feel this should be covered. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this item.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the seat lift. Our reviewer says that the documentation does not support that the criteria are met. Our physician reviewer found There is no objective evidence that the patient has severe arthritis of the hip or a neuromuscular disease. There is a DME order for a motorized seat lift signed by the physician on 5/19/20. The seat lift will not likely effect improvement in the patient's condition or arrest or retard deterioration in the patient's condition. The documentation does not show that the patient is completely incapable of standing from a chair in the home. The patient does not have the ability to ambulate. 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 seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
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 necessary work can be provided in a SNF setting.
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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of
therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or participate in an
IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
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 services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
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 there is no documentation provided requiring admission to a LTACH. The review has
determined that the enrollee does not require services at the LTACH that are not available at the acute care
hospital where they are 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was discharged from
the hospital on August 2, 2020 after a hospital admission for a urinary tract infection. She remains debilitated
and needs mostly modified to maximal assistance with activities of daily living and transfers. The complexity
of his nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an
intensive therapy program 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carboplatin, paclitaxel, and pegfilgrastim.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is receiving carboplatin and paclitaxel for metastatic cancer of gynecological origin. She has become neutropenic. The use of pegfilgrastim to prevent neutropenia is not indicated in this patient not being treated for curative intent but palliative. Instead, a dose reduction would be the standard of care. The combination of carboplatin and paclitaxel with pegfilgrastim is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin, paclitaxel, and pegfilgrastim.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (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 IRF care.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve additional skin cancer treatment doses for the enrollee.
You asked the Plan to pre-approve the additional doses. You say that this is medically necessary. The Plan
denied your request. The Plan says that 35 daily treatment doses are allowed for this treatment course.
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 additional doses. Our reviewer says
that the requested additional doses are considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is being treated with curative intent, with radiation to a squamous cell
carcinoma of the scalp. She is being monitored for residual disease, and after 32 planned fractions was
improved. There was still a viable tumor, and it was proceeded to 35 fractions with improvement. There was
still a small area of viable tumor, and there was a decision to add an additional three fractions with curative
intent. The service is reasonable and medically 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 additional doses have been met. Therefore, we decided that the Plan has to
pre-approve additional skin cancer treatment doses for the enrollee.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's condition can be managed in an outpatient setting, such as the doctor's
office and facility-based therapy.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve your condition, or to establish/perform a maintenance program to maintain your condition and/or
prevent deterioration. You have had prior skilled nursing and were educated in disease management. There are
no complex wounds, new enteral feedings or other skilled nursing need. Your medical conditions are chronic
and generally stable. The records do not show that skilled therapy is needed to effectively provide treatment,
care, and/or services in order to improve your level of function, or to establish/perform a maintenance program
to maintain your level of function and/or prevent deterioration. Your functional level does not require ongoing
skilled therapy. You have had prior therapy and educated in safety. As you do not require skilled therapy or
skilled nursing services, you do not meet the definition of home health aide services per Section 50.2 and the
request for home health aide services are not reasonable and necessary to the treatment of your illness or injury
by the skilled professional staff.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continuation of home health services.