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

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are not having plans or intent to hurt yourself or anyone else.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services were requested beyond January 6, 2020. 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 services. Our physician reviewer found that you were compliant with medication and have not been crying as much. It is not medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to self or others. You did not have any auditory or visual hallucinations while being cooperative/compliant with treatment. Active treatment was not taking place. The services are not reasonably expected to improve your condition, or for the purpose of diagnosis beyond the date in question. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health 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 IRF to stay out of the hospital. The Plan denied your request. The Plan says IRF 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that you require the intensity of an IRF stay with close physician or nursing supervision. You may benefit from and participate in additional physical and occupational therapy but you do not require this on an intensive rehabilitation facility therapy program level 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 Invokamet XR tab 150-1000 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 the requested medication is denied as a benefit exclusion.
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 Invokamet XR tab 150-1000 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee is being held at an inappropriate level of care.The Plan denied your request. The Plan says the records do not indicate that the enrollee meets the criteria for coverage of LTACH care. The plan says that the enrollee can safely receive the necessary care in another setting, such as a skilled nursing facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for sepsis related to gallstone pancreatitis. Our physician reviewer found that the enrollee subsequently developed respiratory failure requiring transient intubation/ventilation. Our physician reviewer found that the enrollee has since been extubated and is no longer on a ventilator. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH and that the enrollee can remain at the current ACH until such a time that no acute services are required. Our physician reviewer found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a greater occipital nerve block.You asked the Plan to pre-approve the a greater occipital nerve block. The Plan denied your request. The Plan says that research has not proven the requested injection to be helpful for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide us with any medical records. We reached out to the Plan requesting this information, and they replied that the medical records were provided with their original submission. Despite this claim, the documentation we have does not include medical records from the in-network referring provider. Without this necessary information, the Plan has not substantiated their denial reason and we cannot evaluate whether the requested injection is medically reasonable and necessary for treatment of the enrollee's condition.  Therefore, we decided that the Plan has to pre-approve a greater occipital nerve block.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo 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 the use of this drug in this case requires the enrollee must have experienced disease progression after platinum-based chemotherapy and at least one other line of therapy.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of the main bronchus. Guidelines support the use of Nivolumab in patients who have documented progression on or after platinum-based chemotherapy. Reviewed records do not support these criteria were met. Without support of the documentation, medical necessity cannot be determined. 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 Opdivo for the enrollee.
Appeal type: SNF
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve Lenvima for the enrollee.You asked the Plan to pre-approve Lenvima. You say that the enrollee has a history of liver cancer.The Plan denied your request. The Plan says that this is not covered under Part B.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 Lenvima for the enrollee.Benefits for Lenvima may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 you are not ready to go home yet. You say that you have difficulty getting around and abed sore that has not healed. You say that you live alone and do not have anyone that can help during your recovery to get stronger. You say that you cannot take more than 12 steps at a time and have stairs in your home. You say that you are having seizures and cannot stand up alone or prepare meals.The Plan denied your request. The Plan says daily skilled care is not needed. The plan says that the enrollee's current therapy needs do not require an inpatient level of care in a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for a urinary tract infection. Our physician reviewer found that the enrollee received physical and occupational therapies in the acute hospital. Our physician reviewer found that the enrollee was a contact guard assist level with functional mobility, including gait to 180 feet with a rolling walker. Our physician reviewer found that the enrollee required varying assist with activities of daily living. Our physician reviewer found that there are no identifiable skilled nursing service needs. Our physician reviewer found that there are identifiable skilled therapy service needs, but that they are not required on a daily basis. Our physician reviewer found that the enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot receive the care she needs in the SNF. IRF would be best for her recovery. The Plan denied your request. The Plan says the criteria for IRF care are not 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 the member was hospitalized from 11/19/2019 through 12/11/2019 with deconditioning, dysphagia, hypertension, and bilateral knee pain. She had SNF level care beginning on 12/21/2019. The member's medical conditions appear stable. There are no wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. There is a primary rehabilitation diagnosis of debility which does not support the medical necessity of acute level rehabilitation. The member requires physical therapy for mobility and endurance. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The member's debility can be appropriately treated by progressing her mobility with the physical therapy treatments being provided. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Oxymorphone 20mg ER tablet medication.You asked the Plan to pre-approvethis medication. You say that this medication has been given to the patient since 2017 as she has lumbar spondylosis, cervical radiculopathy, chronic pain syndrome, lumbar radiculopathy, and a rotator cuff tear.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Oxymorphone 20mg ER tablet medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSUPARTZ FX (J7321).You asked the Plan to pre-approveSUPARTZ FX. You say that this is medically necessary.The Plan denied your request. The Plan says you have not tried Monovisc and Orthovisc as required by step therapy rules.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 SUPARTZ FX. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs Monovisc and Orthovisc before they will approve the requested drug. You have not tried and failed the required drugs, nor does the documentation support that the plan's required drugs would likely be less effective, and/or would likely have adverse effects inthis 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 SUPARTZ FX have not been met.Therefore, we decided that the Plan does not have to pre-approveSUPARTZ FX (J7321).
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 enrollee's medical complexities require nursing care 24 hours a day, and oversight by a medical practitioner.The Plan denied your request. The Plan says the enrollee does not require medical intervention 3 or more times a week.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's current level of function is transfers with moderate assist, supine to sit with moderate assist, maximal assist with donning a hospital gown and shoes, dependent with donning a sling, and ambulating 5 feet with moderate assist of 2. The enrollee is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing physical and occupational therapy, 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 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 enrollee's needs would be best met in an LTACH. The Plan denied your request. The Plan says the enrollee does not require an acute hospital level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are 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 treating provider states a need for daily laboratory monitoring of electrolytes and hemoglobin with daily MD visits. This cannot be accommodated in the skilled nursing setting approved by the health plan. However, it could be accommodated by ongoing care in the current acute care setting until such time as the enrollee is clinically stable for discharge to a lower level of care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care when your total knee replacement procedure is performed.You asked the Plan to pre-approve inpatient level of care. You say that the inpatient admission is necessary.The Plan denied your request. The Plan says based on the documentation provided, the procedure can be done safely at an observation level of care. Therefore, 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 inpatient level of care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided you are medically stable with no evidence of increased risk of surgery. Observation level of care is appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient level of care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient level of care when your total knee replacement procedure is performed