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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee meets the rehab admission criteria under CMS guidelines. You say that the enrollee needs IRF care so she can regain function, ambulate safely, perform activities of daily living, and return home with improved quality of life. 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 necessary 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 currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. Our physician reviewer found that, while she may benefit from continuing physical and occupation 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in an alternate level of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions appear stable. There are no wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. She is ambulating and performing essential activities of daily living without hands-on assistance and does not require an intensive rehabilitation therapy program. The enrollee requires physical therapy for mobility and fall prevention education as well as an evaluation for an assistive device. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The enrollee appears able to participate in and benefit from therapy provided at any level of intensity. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an SNF level or through home based 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) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAmbien.You asked the Plan to pre-approveAmbien. You say that the enrollee has tried and failed other drugs.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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-approveAmbien forthe enrollee.Benefits for Ambienmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDronabinol.You asked the Plan to pre-approveDronabinol. You say that it is important the enrollee keeps up her weight and adequate hydration.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 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-approveDronabinol.Benefits for Dronabinolmay be available under Medicare Part D.Contactthe 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-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee has had double pneumonia, sepsis, and COPD. You say that "the provider" specializes in pulmonary issues. You say that the enrollee needs additional rehab to help her get stronger. You say that "the provider" would also be able to treat the enrollee at night and, if needed, give her a breathing treatment/oxygen if needed.The Plan denied your request. The Plan says the clinical information does not support that the enrollee meets the criteria 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 todetermine 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 is ambulating household distances and requires little assistance with mobility and transfers. Our physician reviewer found that the enrollee does not require skilled nursing services. Our physician reviewer found that, while the enrollee does require skilled therapy services, they are not needed on a daily basis.Our physician reviewer found that 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-approveskilled nursing facility (SNF) services
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAranesp treatments.You asked the Planto pre-approvethe Aranesp. You say that the enrollee needs this treatment due to his condition in order to keep him alive.The Plandenied your request. The Plansaysthe documentation shows that this type of treatment is warranted but that Retacrit, the preferred drug, could be used instead.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 Aranesp. Our reviewer says that the requested treatment is not considered reasonable and necessary based on step therapy requirements. Our physician reviewer found theenrollee is an 81-year-old man with a diagnosis of myelodysplastic syndrome. His hemoglobin level on 12/16/19 was 9.6, and has been stable. The enrollee reported significant fatigue. There has been no trial and failure of the preferred drug. The documentation in the case file does not support that Retacrit would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aranesp have not been met.Therefore, we decided that the Plandoes not haveto pre-approveAranesp treatments.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome skilled nursing services (CPT G0299 and G0300).You asked the Plan to pre-approvethe home skilled nursing services. You say that the records provided support the need for home skilled nursing care.The Plan denied your request. The Plan says the records provided do not show a need for skilled nursing services.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home skilled nursing services. Our reviewer says that the criteria for coverage have not been met Our physician reviewer found the enrollee received oral medications and had stable vital signs. Our physician reviewer found that the enrollee was treated for pain with effect and her incision was healing well. Our physician reviewer found that the records do not show a decline in medical status or a care plan to warrant skilled nursing visits. Our physician reviewer found that skilled nursing visits are not required to effectively provide treatment, care, and/or services which are medically 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 the home skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome skilled nursing services (CPT G0299 and G0300).
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 the medical needs as submitted do not currently require intensive physician or nursing oversight that is present 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to authorize in-network coverage for the long term acute care hospital (LTACH) services to be provided by an out of network facility.
You asked the Plan to authorize in-network coverage for the OON LTACH care. You say that you believe that this should be covered. The Plan denied your request. The Plan says the enrollee may continue to receive the necessary services at the current facility. If OON services are desired, this will be covered under the POS benefit.
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 authorize in-network coverage 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 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 authorize in-network coverage for these items/services. Therefore, we decided that the Plan does not have to authorize in-network coverage for the long term acute care hospital (LTACH) services to be provided by the out of network facility.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the documentation provided supports the need for IRF care. The Plan denied your request. The Plan says that the information provided does not show that the enrollee needs intensive rehabilitation therapy services.
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the enrollee requires intensive rehabilitation, including both physical and occupational therapy, after her recent hip fracture. Our physician reviewer found that the enrollee requires treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer found that physical and occupational therapy assessments document a need for therapy at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days. Our physician reviewer found that there is a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF The enrollee has been fully participatory with post-operative therapy and has indicated a clear desire for intensive therapy with a goal of returning to independent living. 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the thorax without contrast You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that the records do not show results of a recent chest x-ray that were not normal.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee was resected for a ground glass nodule and it is extremely unlikely such a nodule or residual nodule would be visible on a chest x-ray. CT surveillance at regular intervals is medically necessary and appropriate.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the scan have been met.Therefore, we decided that the Plan has to pre-approve CT scan of the thorax without contrast
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulance 3mg tablet.You asked the Plan to pre-approve Trulance 3mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has 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 Trulance 3mg tablet.Benefits for Trulance 3mg tablet 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator for the enrollee.You asked the Plan to pre-approve the ventilator. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no evidence of bi-pap failure.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 ventilator. Our reviewer says that the requestedventilator is medically reasonable and necessary. Our physician reviewer found the enrollee has post-polio syndrome with severe restrictive lung disease and nocturnal hypoventilation. He has been dependent on BiPAP at night and when lying down. Sleep symptoms have been worsening despite BiPAP. A recent PAP titration study showed that BiPAP, even at quite high pressures, did not adequately eliminate the hypopneas, and did not completely alleviate the hypoxemia, even with supplemental oxygen. Therefore a home ventilator is considered reasonable and medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ventilator have been met.Therefore, we decided that the Plan has to pre-approve a home ventilator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the member's condition has worsened since being inpatient at hospital because he's not receiving therapy that's needed.The Plan denied your request. The Plan says that the enrollee does not require daily skilled nursing and/or daily skilled rehabilitation services.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 casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's conditiondoes not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized, and is ready for discharge from the acute care hospital. The Plan denied your request. The Plan says the enrollee is currently tolerating weaning, and all other care is safely being carried out in the current inpatient location.
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 ACH for a hand hematoma. The enrollee arrived on a ventilator and with a feeding tube following a recent stroke following coronary bypass surgery. The enrollee was kept on the ventilator and tube feeds. Her hematoma was drained and wound care provided. While she is currently tolerating CPAP settings, it is unclear if the enrollee is expected to be fully liberated from the ventilator. It does not appear that the enrollee will be decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 admission to a long term acute care hospital (LTACH) for the enrollee.