Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied
your request. The Plan says the service 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 enrollee's medical conditions are stable and there are no complex nursing or
rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy,
there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be
obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has anemia on chronic kidney disease. She has not tried and failed the Plan's required drug, Retacrit. The records do not show that the required drug would be contraindicated or less effective; therefore, Procrit 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 Procrit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracoscopy and inpatient hospital stay.

You asked the Plan to pre-approve thoracoscopy. You say that the records strongly support the medical necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this service is helpful for treatment of the enrollee's condition.

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 thoracoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food & Drug Administration states that the AtriCure Synergy Ablation system is intended to ablate cardiac tissue for the treatment of persistent atrial fibrillation or long-standing persistent atrial fibrillation in patients who are undergoing open concomitant coronary artery bypass grafting and/or valve replacement or repair. The record indicates that the enrollee has persistent atrial fibrillation refractory to medical treatment. The record does not indicate that the enrollee is undergoing open concomitant coronary artery bypass grafting and/or valve replacement or repair. This service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thoracoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve thoracoscopy and inpatient hospital stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is presenting to the hospital for an elective non-emergent incision and drainage, VAC placement, and skin grafting for a right below the knee wound. No signs of infection were present and past medical history was significant for hyperlipidemia. Based on the provided documentation the patient is stable and does not warrant hospital care that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not
contain documentation of a trial of Remicade, Inflectra, or Simponi Aria. The documentation does not support
that Remicade, Inflectra, or Simponi Aria would likely be less effective, and/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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orencia 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 you disagree with the denial. The Plan denied your request. The Plan says the 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 8, 2021 for worsening necrosis of toes 2 and 3 of the left foot and a diabetic ulcer on the right foot. There is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were provided in good faith for reimbursement. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were self-referred.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on March 18, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that you have two clogged arteries and need this item. The Plan denied your request. The Plan says that the record does not indicate you have open venous stasis ulcers.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
You asked the Plan to pre-approve the continuation of care with an OON provider. You say that the enrollee would like to proceed with the scheduled procedure with the provider she has been seeing. The Plan denied your request. The Plan says the services needed can be provided within the network medical group.
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 continuation of care with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical management of her condition that makes it medically necessary for this enrollee to continue care with the out-of-network provider as requested. There is not anything unique about this enrollee's condition that would make it medically necessary for her to continue care with the out of network provider. The plan shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. The Plan noted that they have a provider in network provider that performs the scheduled knee arthroscopy procedure and earliest appointment would be on September 2, 2021. Surgery is scheduled for September 7, 2021. The enrollee's medical management and/or follow-up care be safely transitioned to an in-network specialist at this time. 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 continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472) in an acute inpatient hospital setting.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says the total shoulder arthroplasty (23472) has been approved, but only on an outpatient basis. The associated inpatient hospital stay is not medically necessary or reasonable for the requested procedure.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found the clinical documentation shows that the enrollee has a past medical history of significant hypertension, but there is no other information that suggests that this enrollee is at a higher risk or would require complex care following the requested surgery. The documentation does not show that the enrollee requires hospital care that would likely cross two midnights. It is not medically necessary for the total arthroplasty to be provided on an inpatient basis according to the provided records. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472) in an acute inpatient hospital setting
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 require this level of care. The Plan denied your
request. The Plan says that this request exceeds your level of need.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for an occipital stroke. Your
medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the documentation does support a need for physical
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition
does not meet Medicare criteria for IRF 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 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 the service is medically necessary. The Plan denied
your request. The Plan says the service 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 your medical conditions are stable and there are no complex nursing or rehabilitation
needs. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be
obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
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: Favorable

We decided that the Plan has to approve acute inpatient hospital care.
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
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 approve acute inpatient hospital care. Our reviewer says that the criteria for coverage are met. Our physician reviewer found the enrollee presented to the hospital with shortness of breath due to chronic obstructive pulmonary disease exacerbation that had lasted several days. She also had chest pain. She was started on systemic steroids. She had several other acute issues that required addressing. The records support that the treating physician had a reasonable expectation that the enrollee would require at least two midnights of inpatient hospital care. The inpatient services are 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to approve acute inpatient hospital care.
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.