Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says the enrollee has not
tried and failed Ruxience and Truxima.
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 Rituxan. Our physician reviewer found
that the enrollee has a diagnosis of Microscopic polyangiitis. The Plan requires a trial of Ruxience and Truxima
before they will approve the requested drug. The case file does not support that the required drugs have been
tried and failed. The documentation does not support that the required drugs would likely be less effective or
would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Rituxan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for dental services.
You asked the Plan to pre-approve anesthesia services. You say that you would not be able to tolerate the pain
while staying awake during the procedure. The Plan denied your request. The Plan says the service is not
covered under your benefit package.
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.
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve anesthesia
for dental services.
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 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke, hypertensive emergency and urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 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 IRF admission and services.
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 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for radical cystectomy and ileal conduit. Post-operative complications included atrial fibrillation and sepsis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you do not need skilled services at least 5 days per week, does not
require supervision of a physician and has current needs that can be safely met at a less intensive care setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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 continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for 17 units of independent nursing services (T1000) provided on June 28, 2020.
You asked the Plan to pay for the independent nursing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the number of units 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 T1000 is private duty/independent nursing service(s) - licensed, up to 15 minutes. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the independent nursing services. Our reviewer says that CPT code T1000 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation includes a home visit lasting 4 hours. 4 hours divided by 15 minutes equals 16 units. Therefore, 17 units cannot be confirmed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the independent nursing services have not been met. Therefore, we decided that the Plan does not have to pay for 17 units of independent nursing services (T1000) provided on June 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.

You asked the Plan to pre-approve continued inpatient mental health care. You say that this is medically
necessary. 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 inpatient psychiatric services may be covered if the
patient requires active treatment.

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 continued inpatient mental health care.
Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found
the enrollee does not appear to require inpatient mental health treatment beyond what the Plan previously
approved as she is not a danger to herself or others and does not have any auditory or visual hallucinations
while being cooperative with treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient mental health care have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living with daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 is at risk for injury from falls, infection complications, and skin breakdown. The Plan denied your request. The Plan says the enrollee's care is not complex, and she does not need a team of providers.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 was admitted to the acute hospital for presyncope and metabolic encephalopathy. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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: 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 this is medically necessary. The Plan denied your request. The Plan says you could 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 in the Medicare rules section. 

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 your current medical condition does not require intensive physician or nursing supervision in an IRF. While you may benefit from additional physical and occupational therapy, the documentation does not reveal that this therapy must be only on an intensive level in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. Additionally, there is no documentation provided that indicates the patient requires an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Favorable

We decided that the Plan has to pre-approve Trastuzumab-dkst and Pertuzumab.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says that the drug combination is not supported for the enrollee's cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested drugs. Our physician reviewer found that the requested drugs are not FDA-approved for the enrollee's diagnosis. However, the requested use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. a small percentage of the AFFINITY trial received just Trastuzumab and Pertuzumab with improvement in disease free survival. This is a common regimen used in older adults not felt to be candidates for chemotherapy. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested drugs have been met. Therefore, we decided that the Plan has to pre-approve Trastuzumab-dkst and Pertuzumab.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from May 4, 2021, forward.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says psychiatric hospitalization while waiting to go to a state hospital is not an active treatment and the continued stay at the current level of care is no longer medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient mental health care. physician reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as they were not a danger to themself or others and did not have any auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 4, 2021, forward as this enrollee was not shown to be a danger to themself or others. The enrollee was not presenting any auditory or visual hallucinations while not showing any threats the safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from May 4, 2021, forward.
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. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and does not require transfer.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for acute on chronic hypoxic respiratory failure, gram negative pneumonia and COPD exacerbation. At this time, his status is unstable. He 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 he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are 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 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.