Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from
June 7, 2021, and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from June 7, 2021, and
forward. You say that the continuation of inpatient mental health care from June 7, 2021, and forward is
medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health
care from June 7, 2021, and forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient mental
health care from June 7, 2021, and forward. Our reviewer says that the continuation of inpatient mental health
care from June 7, 2021, and forward is not medically necessary. Our physician reviewer found this enrollee did
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to
herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment.
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the
services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond
the date in question. I am unable to find an individualized treatment plan however the entire chart is not
present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the
records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment
for the dates in question of June 7, 2021, and forward as this enrollee was not shown to be a danger to herself
or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with
treatment while not showing any threats to safety.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continuation of inpatient mental health care from June 7, 2021, and forward
have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of
inpatient mental health care from June 7, 2021, and forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted due to weakness and shortness of breath with an obstructing bronchial lesion. On June
11, 2021, the enrollee had a type II myocardial infarction. The enrollee continues to receive acute care services
that have not been denied. The medical records provided do not indicate that the enrollee requires acute care
services that she is not currently receiving that would be available at the LTACH. The elements of the coverage
rules are not satisfied. The requested 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. 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 acute respiratory failure and pulmonary edema. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted due to severe pneumonia and sepsis due to COVID-19 infection and required extracorporeal membrane oxygenation (ECMO). The enrollee has a fever, is tachypneic and tachycardic. The enrollee continues to receive acute critical care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied. The requested 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 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 pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are in-network providers available to you that can provide the services you are requesting.

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 physical therapy services to be provided by an out of network (OON) provider.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
enrollee does not meet criteria for IRF admission. 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 diabetic ketoacidosis and right
lower extremity cellulitis. He had a below the knee amputation. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc One first.

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 Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with knee pain from osteoarthritis. Euflexxa was requested. The provided records do not show evidence of the enrollee having tried and failed either Visco-3, Gel-One, Orthovisc, Synvisc, or Synvisc One. The provided records and current literature does not suggest that the preferred medications would be less effective or increase risk of adverse effects compared to Euflexxa as they all have essentially equal safety and effectiveness, and there was no exceptions described in the notes.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept device for Intraosseous Basivertebral Nerve Ablation.

You asked the Plan to pre-approve an Intracept device for Intraosseous Basivertebral Nerve Ablation. You say that the requested Intracept device for Intraosseous Basivertebral Nerve Ablation is medically necessary. The Plan denied your request. The Plan says the requested Intracept device for Intraosseous Basivertebral Nerve Ablation is not medically necessary.

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 an Intracept device for Intraosseous Basivertebral Nerve Ablation. Our reviewer says that the requested Intracept device for Intraosseous Basivertebral Nerve Ablation is not medically necessary.

Our physician reviewer found the enrollee is with continued low back pain. The Intracept procedure remains experimental for low back pain. 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 an Intracept device for Intraosseous Basivertebral Nerve Ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept device for Intraosseous Basivertebral Nerve Ablation.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. 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 kidney stone. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: 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 will not be safe at home alone and would risk readmission to the hospital. You say that you need acute rehab services. 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 can safely receive the care needed in other settings.
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 infection of previous hip replacement and had new artificial hip placed. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injection services.

You asked the Plan to pre-approve the Botox injection services. You say that the records provided support the
need for the Botox injection services being requested. The Plan denied your request. The Plan says the
requested services are not medically necessary.

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 Botox injection services. Our
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has
epigastric pain and a diagnosis of a gastric ulcer. She experiences symptoms of nausea, spasms, and difficulty
swallowing. Pyloric stenosis and gastroparesis have also been diagnosed. The listed diagnoses are not listed in
the Medicare coverage criteria for Botox use. The documentation does not sufficiently support that Botox
would be safe and effective for the enrollee, as there is insufficient high-quality evidence that this procedure
would provide long-lasting benefit over standard and conservative treatments, including lifestyle changes.

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 Botox injection services have not been met. Therefore, we decided that the
Plan does not have to pre-approve Botox injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 the home visit provided on January 20, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Tricor 145 mg tablet.
You asked the Plan to pre-approve Tricor. You say that the requested drug kept your blood test values in a safe range and was covered at least partly by your previous insurance. The Plan denied your request. The Plan says rules for self-administered drugs have 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 treatment with Tricor 145 mg tablet.
Benefits for Tricor may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.