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 askes.ed the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the needed care 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 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 was hospitalized on June 4, 2020 with status epilepticus. His hospital course was complicated by pneumonia, sepsis, myocardial infarction, and renal failure, requiring hemodialysis. The enrollee's seizures have been controlled and he is no longer requiring dialysis. Therapy is limited by the enrollee's impaired cognition. He follows 1 - 2 word commands approximately 75% of the time. The complexity of the enrollee's nursing, medical, and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy. An intensive rehabilitation therapy program is not required. 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 servic
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroplasty surgery.
You asked the Plan to pre-approve sacroplasty. You say that you cannot afford this surgery out-of-pocket. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is considered experimental/investigational.
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 sacroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although limited evidence suggests that sacroplasty relieves the symptoms of sacral fractures, substantial uncertainty exists due to the shortage of comparative studies and individual study quality limitations of the eligible studies. Studies comparing sacroplasty with conservative measures and other interventions are needed. This is considered an experimental/investigational procedure 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 sacroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroplasty surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe office visits to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON office visits. You say that the provider you would like to see is closer to you.The Plan denied your request. The Plan says there are multiple in-network providers in your area that can provide the requested services.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe office visits to be provided by an out of network (OON) provider.
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 the services. You say that this is medically necessary. The Plan denied your request. The Plan says available coverage will expire on 7/1/20. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled therapy services. The specialized skill, knowledge and judgement of a skilled professional nurse or a qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. You do not require the services on 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 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: 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 necessary for the enrollee's ability to regain function. The Plan denied your request. The Plan says the enrollee would not tolerate an intensive rehabilitation program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require, or to be able or willing to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex.You asked the Plan to pre-approve the Darzalex. You say that you would like reconsideration as this drug is medically necessary.The Plan denied your request. The Plan says the FDA has not approved the requested medication for treatment of the submitted medical diagnosis and in this setting its use is considered off-label.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Darzalex. Our reviewer says that Daratumumab is not FDA approved for the treatment of smoldering multiple myeloma. It is not supported by major drug compendia for off-label use or the medical literature Our physician reviewer found the safety and efficacy for this member's condition is unclear. The service 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 the Darzalex have not been met.Therefore, we decided that the Plan does not have to pre-approve Darzalex.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac joint injections (27096).You asked the Plan to pre-approvesacroiliac joint injections. 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. 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 sacroiliac joint injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not had an adequate trial of conservative therapy. Conservative therapies should be trialed before any interventions. The requested procedures are not medically reasonable or necessary 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 sacroiliac joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac joint injections (27096).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient hospital care.
You asked the Plan to pre-approve continued inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient hospital care. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found as the enrollee had spinal instability, ongoing medical issues and pending surgery, evaluation and management, the inpatient setting appears to be the safest and most expeditious manner of providing care. The health plan has failed to show that the services are not medically necessary or that they are unreasonable. 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 hospital care have been met. Therefore, we decided that the Plan has to pre-approve continued 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation and tooth extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve an evaluation and tooth extractions to be provided by an oral surgeon. You say that you need to see an oral surgeon due to a cavity under the root of your teeth. The Plan denied your request. The Plan says services provided by an oral surgeon are not covered.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, services provided by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an evaluation and tooth extractions to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve pneumatic compression device. You say that this is the only vendor that supplies the type of device you need.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be provided by an in-network supplier.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network
psychiatrist.
You asked the Plan to pre-approve the continuation of care with an out of network psychiatrist. You say that
you have been seeing the requested out of network provider for 20 years. You say that it would be hard for you
to start seeing a new psychiatrist. You say that the relationship between yourself and the psychiatrist is very
important. The Plan denied your request. The Plan says the one transition of care visit with the out of network
doctor will be sufficient. The Plan says that the services required by the enrollee are available from an in
network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the continuation of care with an out of network psychiatrist 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 psychiatrist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381).
You asked the Plan to pre-approve the localized delivery of antimicrobial agents. You say that you need this due to life threatening gum disease. The Plan denied your request. The Plan says this is excluded from coverage.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve bone marrow aspiration. You say that this is medically necessary. The Plan denied your request. The Plan says there is not evidence that the use of bone marrow aspirate increases fusion rates.
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 bone marrow aspiration. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in cases in cases of lumbar spinal fusion surgery. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions to be performed by an oral surgeon.
You asked the Plan to pre-approve tooth extractions to be performed by an oral surgeon. You say that you were told you need to see an oral surgeon. The Plan denied your request. The Plan says services provided by an oral surgeon are not covered.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, services provided by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve tooth extractions to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient behavioral health care.You asked the Plan to pre-approveinpatient behavioral health 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. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health care have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established.Therefore, we decided that the Plan does not have to pre-approveinpatient behavioral health care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve36 physical therapy (PT) visits.You asked the Plan to pre-approve36 PT visits. You say that the requested services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 36 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found you are not shown to require outpatient PT multiple times per week. You are months out from your hip fracture and surgery. You are ambulatory and performing various exercises. Your care needs can be met 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 36 PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve36 physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Brovana (arformoterol).You asked the Plan to pre-approveBrovana. You say that the enrollee needs Brovana to open her airways.The Plan denied your request. The Plan says the denial of authorization for Brovana is correct, because the enrollee is also using Trelegy Ellipta and Brovana requires that the enrollee not be using other drugs that contain long-acting beta-2 agonists.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Brovana. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested Brovana. Our physician reviewer found Brovana is a long-acting beta agonist (LABA) administered by nebulization. The enrollee is already on Trelegy which contains a LABA. Therefore, Brovana is contraindicated because of duplicate LABA therapy with risks of cardiac effects. Brovana is therefore not medically reasonable or necessary 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 Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Brovana (arformoterol).
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 prefer admission to the IRF because you want to be able to go home in 7 to 10 days which is not possible in a nursing facility. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies and an intensive rehabilitation therapy 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. Your rehabilitation needs can be met in a lower intensity setting such as skilled nursing facility. 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.