Persius/hicric huggingface dataset:
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 LTACH is necessary for this enrollee. The Plan denied your request. The Plan says the enrollee needs can be met at an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 70 year old female who was admitted to the acute hospital on 12/26/19 with respiratory failure, pneumonia, chronic obstructive pulmonary disease exacerbation and interstitial lung disease - she has been treated for these as well as sepsis and urinary tract infection. Patient is deconditioned and working with physical therapy and occupational therapy. Transfer to a long term acute care hospital (LTACH) requested. The documentation does not support that the enrollee requires services that are not available at the current facility. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, criteria for a step therapy exception has not been met.
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. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the patient has tried and failed the required drug. The provided medical records also do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET/CT scan from head to thigh.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says that the prior study was sufficient to show the doctor what was needed in order to treat
this condition.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the scan. Our reviewer says that the
requested scan is medically reasonable and necessary. Our physician reviewer found the requested PET/CT is
reasonable and necessary in light of the negative surgical biopsy in the chest within the past 8 months and the
rising CEA level as well as the findings on the prior PET/CT. The PET/CT will have implications regarding the
nature of disease within the chest and whether there is evidence of distant metastasis in this patient with a
history of Stage II colon cancer. This study will be crucial for surgical and oncologic planning especially since
prior thoracotomy yielded negative biopsy for malignancy.
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 scan have been met. Therefore, we decided that the Plan has to pre-approve
PET/CT scan from head to thigh.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Solifenacin 10mg tablet.You asked the Plan to pre-approve Solifenacin 10mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Solifenacin 10mg tablet. Benefits for Solifenacin 10mg tablet 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea high dosage flu shot.You asked the Planto pre-approvethe vaccine. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Even though the influenza virus is an exception to the vaccine non-coverage rule, the high dose version is not listed. The plan also specifically excludes the high dose version.Therefore, we decided that the Plandoes not haveto pre-approvea high dosage flu shot.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pay forthe surgery at L1. We decided that the Plan does not have to pay forthe surgery at T11. You asked the Plan to pay forthe procedure. You say that this is medically necessary.The Plan says that this is not medically necessary.We decided that the Planhas to pay forthe surgery at L1. The Plan follows Medicare rules. Medicare rules say that kyphoplasty and vertebroplasty is covered for acute fractures.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 for the procedure at L1. Our reviewer saysthat the L1 vertebral body fracture meets the LCD criteria and is medically reasonable and necessary. Our physician reviewer found you have chronic low back pain and two vertebral body fractures. The L1 fracture has evidence of end plate edema which indicates it is still acute.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 surgery at L1 have been met.Therefore, we decided that the Plan has to pay forthe surgery at L1. We also decided that the Plandoes not have to pay forthe surgery at T11.The Plan follows Medicare rules. Medicare rules say that kyphoplasty and vertebroplasty is covered for acute fractures.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 the procedure at T11. Our reviewer says that the T11 body fracture does not meet LCD criteria, and is not medically reasonable or necessary. Our physician reviewer found that the T11 fracture is chronic.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 surgery at T11 have not been met.Therefore, we decided that the Plan does not have to pay forthe surgery at T11.
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 therewas 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea health club program at "the wellness center". You asked the Plan to pre-approvea health club program at "the wellness center". You say that this facility is the best suited for your needs.The Plan denied your request. The Plan says the facility is out-of-network. Therefore, coverage criteria has not been met.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only through the SilverSneakers fitness program.The Plan's rules for coverage of gym benefits have not been met because "the wellness center" is an out-of-network facility.Therefore, we decided that the Plan does not have to pre-approvea health club program at "the wellness center."
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca for the enrollee.
You asked the Plan to pre-approve Belbuca. You say that Belbuca is more appropriate for the enrollee given its superior side effect profile. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belbuca for the enrollee.
Benefits for Belbuca 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received in another 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 relevantMedicare 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, skin care, and daily therapy can be provided at a SNF.A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires daily therapy in the SNF setting to recover. The Plan denied your request. The Plan says the enrollee's condition is stable and no daily skilled services are required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 90 year old female admitted to the hospital with hip fracture. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at maximum to total assist level for functional mobility including gait to a few steps with hand held assistance. The beneficiary required varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, skilled therapy is not required on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care, such as in the home with physical and occupational therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for skilled nursing services. The provided records do not indicate a need for daily skilled services. The provided medical records do not indicate a need for inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat neurolysis facet nerve for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says there is no information proving that the prior procedure provided more than 50% pain relief for at least six months.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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does NOT clearly state the degree and duration of pain relief following the RFA of 3/22/19. The 3/8/19 injection appears to have been a set of diagnostic MBBs with greater than 80% pain relief. But there are no follow up notes in the interval submitted after the RFA. Therefore, the request is deemed 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a repeat neurolysis facet nerve for the enrollee.
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 the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee's needs are custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, clear lungs, and was treated for pain with effect. Our physician reviewer found that the enrollee received physical and occupational therapy in the acute hospital. Our physician reviewer found that the enrollee was at stand by assist to minimal assist levels with functional mobility, including gait to 5 feet with a rolling walker. Our physician reviewer found that the enrollee required varying assist with activities of daily living. Our physician reviewer found that the enrollee could bear weight as tolerated in a postop shoe. Our physician reviewer found that there are no identifiable skilled nursing service needs. Our physician reviewer found that there are identifiable skilled therapy service needs, but that they are not required on a daily basis. Our physician reviewer found that the enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intensive therapy. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for acute renal failure and respiratory failure secondary to pneumonia. She has responded to medical management and is now back to medical baseline, but is significantly debilitated and needs modified/maximal assist for overall transfers, mobility, and activities of daily living. She does not have complex medical or nursing issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear that she would be able to fully benefit from and participate in 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 for the enrollee.
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 enrollee requires LTACH admission for the continuation of care for complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says the enrollee could have the care needed at an alternate level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for aspiration pneumonia in the setting of a baseline tracheotomy and feeding tube. Our physician reviewer found that the enrollee was placed on a ventilator and provided with antibiotics. Our physician reviewer found that the enrollee's feeding tube type was changed and that the enrollee remains on a ventilator. Our physician reviewer found that there is no evidence that ventilator weaning has been attempted or is even planned and decannulation is not expected. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required and can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.