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 setting has the care that you need to recover. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS-3D analysis (88361, 88312) provided on January 19, 2021.

You asked the Plan to pay for the WATS-3D analysis. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says that the submitted documentation doe not include a complete report to verify the clinical utility of the test.

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 pay for the WATS-3D analysis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the available record does support the high likelihood of Barrett's esophagus in the member's case, and thus does meet the spirit of American Society for Gastrointestinal Endoscopy guidance relative to medically necessary use of the WATS-3D service under review. 

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 WATS-3D analysis have been met. Therefore, we decided that the Plan has to pay for WATS-3D analysis (88361, 88312) provided on January 19, 2021.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional speech therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says 27 speech therapy visits is enough for teaching, education, and therapy for improvement in functional capacity and adoption to impairments from the stroke.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee can transition to an independent home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional speech therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a special respiratory assist machine (E0466).
You asked the Plan to pre-approve the respiratory assist machine. You say that the respiratory assist device is necessary for the enrollee. The Plan denied your request. The Plan says this device is only covered for neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease and is therefore uncovered.
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 respiratory assist machine. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have an enumerated condition for which coverage is available. 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 respiratory assist machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a special respiratory assist machine (E0466).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the spine (72148).

You asked the Plan to pre-approve an MRI scan of the spine. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan of the spine. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that more conservative measures are needed. There needs to be a recent and adequate trial of physical therapy for back pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI scan of the spine have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the spine (72148).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for an echocardiography for the enrollee.
You asked the Plan to pre-approve the referral. You say that an out-of-network referral for an echocardiography The Plan denied your request. The Plan says there are no valid network rules override reasons.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 referral. Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found the enrollee has stable symptoms and is undergoing a cardiac evaluation with echocardiography to assess left ventricular function in the setting of possible cardiovascular disease. As the enrollee is clinically stable and undergoing an outpatient evaluation, the echocardiogram is an elective procedure and can be reasonably and safely done in an accredited in-network lab facility and the results of the testing sent to his treating provider. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for an echocardiography for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Inflectra at a dosage of 5 milligrams (mg) per kilogram (kg) every 8 weeks.
You asked the Plan to pre-approve Inflectra. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug dosage is correct, because the standard dosing of Inflectra for the enrollee's condition is 3mg/kg per 8 weeks which can be increased if the enrollee does not have an adequate response to this dose.
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 Inflectra. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested dosage level of Inflectra. Our physician reviewer found Inflectra at the requested dosage level of 5mg/kg per 8 weeks is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis as the records do not document an inadequate response to standard dosing of 3mg/kg per 8 weeks. This dosage level is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal in the absence of documented failure of standard dosing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Inflectra at a dosage of 5 milligrams (mg) per kilogram (kg) every 8 weeks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Minuteman interspinous spacer (22869, 22612).

You asked the Plan to pre-approve the insertion of a Minuteman interspinous spacer. You say that the enrollee has failed other treatments. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Minuteman interspinous spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Minuteman spacer is experimental. More research is needed to show that it is safe and effective.

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 insertion of a Minuteman interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Minuteman interspinous spacer (22869, 22612).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for admission to an inpatient hospital.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee could have been safely observed without the need for admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would span two midnights We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for admission to an inpatient hospital.
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 25 additional skilled nursing home health visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the available data does not document clinical instability or medical management requiring continued home skilled nursing services.
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 additional visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found it is unclear if the enrollee is truly homebound. The enrollee's surgical incisions appear to be well-healed and no longer receiving significant wound care. The enrollee has friends and family available to provide assistance. As such, the requested ongoing services are not shown to be needed. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 25 additional skilled nursing home health visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Aflibercept injections (J0178) provided from December 4, 2020, through April 2, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.

You have been asked to pay $1,107.55 (Plan allowed amount of $5,537.74 x 20% coinsurance) for the Medicare Part B drug injections provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Aflibercept injections (J0178) provided from December 4, 2020, through April 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MYRBETRIQ Tablet ER 24HR 50MG.

You asked the Plan to pre-approve the MYRBETRIQ Tablet ER 24HR 50MG. You say that the item is medically necessary. The Plan denied your request. The Plan says they do not cover this drug.

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 the MYRBETRIQ Tablet ER 24HR 50MG.

Benefits for the MYRBETRIQ Tablet ER 24HR 50MG may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that it is not safe for the enrollee to go home. You say that the enrollee needs assistance around the clock. You say that the enrollee is ready to be discharged from the hospital. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs and was treated for pain and a UTI. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a contact guard to stand-by assist for functional mobility including gait to 165 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent injection.

You asked the Plan to pre-approve Dupixent. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent injection.

Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a craniotomy for resection of a frontal brain mass. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.