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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested services are necessary.The Plan denied your request. The Plan says based on the documentation provided, your needs can be met at a lower level of care. Therefore, coverage criteria for IRF care has not been met.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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact your condition differently compared with therapy provided at a less intense level. Your care can be appropriately provided at an SNF level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea hematology/oncology consult with a tertiary provider.You asked the Plan to pre-approvetertiary services. You say that you have severe pain from your nerves, and you do not want to lose full control of your legs.The Plan denied your request. The Plan says advanced special care 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 tertiary services. Our physician reviewer found that you have a history of breast cancer, hypercoagulable condition with prothrombin gene mutation and antiphospholipid syndrome and history of deep veinthrombosis. You are presently having symptoms of back pain and impingement neuropathy despite conservative treatment. You have been referred to a tertiary level hematologist/oncologist for evaluation in case you need surgery. The records do not indicate that a non-tertiary provider would be unable to manage the issue of your anticoagulation with regard to your present conditions.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tertiary services have not been met. Therefore, we decided that the Plan does not have to pre-approvea hematology/oncology consult with a tertiary provider.
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 SNF care. The Plan denied your request. The Plan says this is not medically necessary.
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 an 88 year old female admitted to the hospital with pneumonia. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. She used oxygen via nasal cannula. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a contact guard to minimal assist with functional mobility including gait to 72 feet with a rollator walker. The beneficiary required varying assist with ADLs from set up to minimal assist. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says therapy can be received in a different location.
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 you are currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. While you may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe radiation oncology services to be provided by out of network (OON) provider, "the out of network doctor".You asked the Planto pre-approvethe OON radiation oncology services. You say that the in-network providers being offered for this care have bad reviews and one treated another family member who was dissatisfied. You believe that the enrollee should be allowed to receive all care from OON providers at the "out of network provider".The Plandenied your request. The Plan says surgical oncology services were approved from "in network doctor" at "out of network facility" as this provider does contract with the Plan, though the Plan does not contract with the"out of network facility" office. There are network radiation oncologists who can provide the care needed. As such, there is no need to approve OON care.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who canprovide 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 Plandoes not haveto pre-approvethe radiation oncology services to be provided by out of network (OON) provider, "out of network doctor".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires and would benefit from daily physician visits, and intensive therapies to optimize mobility.The Plan denied your request. The Plan says the enrollee's condition is not medically complex, and does not require an interdisciplinary approach to oversee rehab care.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 physician reviewer found that in this case, the enrollee has hypertension and intermittent confusion. She has GI dysmotility. Medically, she is non-toxic and afebrile. She is at moderate assist for lower body activities of daily living, supervised for gait, and minimal assist overall for transfers. The enrollee does not require treatment bymultiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of the enrollee's  patients nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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-approveacute 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 are not able to walk and need assistance from nurses. You say that your bones are not strong, that you are a fall risk, and that it is not safe for you to go home.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 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 is stable with no nursing interventions needed. Our physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee has no medical complexity and her mobility functional level does not require therapy for 3 hours a day. Our physician reviewer found that the enrollee's rehabilitation needs can be met at a skilled nursing facility (SNF) 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 services are medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 21, 2019 and is on total parenteral nutrition and has a feeding tube, but records indicate he has not been tolerating the tube feedings due to an ileus. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. He does not require services at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The LTACH services are 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 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 a Supartz injection.
You asked the Plan to pre-approve the Supartz injection. You say that the x-rays show degenerative changes in the left knee. You say that you have pain and joint line tenderness. You say that you have tried and failed physical therapy and steroid injections. The Plan denied your request. The Plan says the information submitted does not meet the medical necessity guidelines for coverage. The plan says that the enrollee has not had previous treatment, contraindication, or intolerance with Orthovisc and Monovisc.
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 Supartz injection. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of the drugs Orthovisc and Monovisc first, before they will approve the requested drug. Our physician reviewer found that the provided medical records do not indicate that the enrollee has tried and failed the required drugs. Our physician reviewer found that the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely to 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 the Supartz injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Supartz injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee has chronic lymphedema and it has been worsening. You say that it is imperative to begin the therapy immediately to avoid further complications.The Plan denied your request. The Plan says the enrollee does not have swelling in the chest, trunk or abdomen. The plan says that the enrollee did not fail a four week trial of a basic lymphedema pump model without calibrated pressure for at least 3 minutes per day.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. In addition, the records provided do not show that the enrollee has lymphedema extending onto the chest, trunk, and/or abdomen that extends past the limits of a standard compression sleeve.Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armodafinil 150mg tablet.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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 Armodafinil 150mg tablet.
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 enrollee has been falling frequently during transfers. You say that he is not able to sit up on his own and requires maximum assistance and 2 person assist to get out of bed and into a chair. You say that it is not safe for the enrollee to go home and that he is experiencing confusion. You say that the enrollee needs therapy to regain strength. The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care or daily skilled rehabilitation therapy. The Plan says that the enrollee's condition does not meet the requirements for coverage of SNF care.
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 does not require skilled nursing services. Our physician reviewer found that the enrollee does require skilled therapy services, but not on a daily basis. Our physician reviewer found that, as a practical matter, the enrollee does not require the necessary 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 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-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs around the clock care and rehab.The Plan denied your request. The Plan says it is not clear the enrollee is able to participate in the level and intensity of therapy required in an IRF.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 physician reviewer found that the enrollee has significant cognitive deficits and is mostly maximal to moderate assist for transfers. Toilet/hygiene care is total assist.  It is not clear the member would be able to fully benefit and/or participate in an IRF level of care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says it remains unclear how the enrollee would benefit from long-term acute care hospitalization. The plan says that the enrollee has not met the criteria for LTACH care because of her declining condition. The plan says that once the enrollee is medically stable, she can transition to a lower 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 there are no services required by the enrollee which are available at the LTACH and not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee is getting the necessary services in the present acute care hospital. Our physician reviewer found that continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care. Our physician reviewer found that the records indicate that the enrollee is eligible for hospice care and it is not clear what else could be provided for the enrollee in an LTACH.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-approvelong term acute care hospital (LTACH) services