Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approverepeat transthoracic echocardiography for the enrollee.You asked the Plan to pre-approvethe study. You say that this is medically necessary.The Plan denied your request. The Plan says that the prior study and clinical provided do not show a clear need for a repeat study at this time.The Plan must follow Medicare rules. Medicare rules say that repeat echocardiography is covered if there a documented reason for the repeat testing.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 study. Our reviewer says that the requested services areconsidered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had recent congestive heart failure with new global reduction in left ventricular ejection fraction. He has clinically improved with medical therapy. In this setting of a substantial clinical change, reevaluation of ejection fraction with repeat echocardiography is reasonable and appropriate to help guide cardiac treatment. For example, if the ejection fraction remains decreased or further decreases then the patient my benefit from additional therapy whereas if the ejection fraction normalizes then recommended therapy would differ. Coverage criteria are met since one covered indication includes "Repeat studies are appropriate to monitor changes in cardiac structure or function when there are changes in the clinical status of the patient."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 study have been met.Therefore, we decided that the Plan has to pre-approverepeat transthoracic echocardiography for the enrollee.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLevalbuterol HCl at a tier exception for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the drug is not eligible for a tier exception.The Plan must follow Medicare rules. The rules say that Part B drugs are not eligible for a Part D tier exception.We looked at the file and Medicare rules. The requested drug is covered by Part B Medicare and is not eligible for a Part D tier exception.Therefore, we decided that the Plan does not have to pre-approveLevalbuterol HCl at a tier exception for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveroutine transportation to an appointment 90 miles from your home.You asked the Planto pre-approvethe 90 mile trip. You say that you need this trip approved so you can go to your medical appointment.The Plandenied your request. The Plansaysyour routine transportation benefit does not cover a trip of over 50 miles.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plandoes not haveto pre-approveroutine transportation to an appointment 90 miles from your home.
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 records provided support the need for IRF care.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the hospital records show that the enrollee's medical conditions have improved and that he can safely receive care in a less intensive setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by physical medicine and rehabilitation Physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on medical stability. The clinical information provided did not support the medical necessity for Inpatient Rehab. The enrollee's therapy needs can be met at a lower intensity rehab such as in a skilled nursing facility (SNF) setting.We looked at this physician'sreview, 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-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.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 LTACHcare is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materiallydifferent than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care, oxygen supplementation, suctioning, analgesia, surveillance laboratory studies, frequent pressure relief turning,and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan doesnot have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received 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 complexity of the patient's 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 the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscontinuedrehab needs can be met at a skilled nursing 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 was medically stable status-post SDH and craniotomy on 11/8/19, with no recent additional neurological or orthopedic events and there is no evidence of complex medical issues that require monitoring with no evidence of need for supervision by a PMR physician or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMultaq for the enrollee.You asked the Planto pre-approveMultaq. You say that the enrollee has been on the same medication for years with no problems.The Plan denied your request. The Plan says the medication does not fall 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-approveMultaq for the enrollee.Benefits for Multaqmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee presented with altered mental status and slurred speech for 3 days. The enrollee was found on the floor by family.  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. The documentation does notreveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 indenying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital with nausea, vomiting and pain. From a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. She was treated for her GI symptoms. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a modified independent level with bed mobility and required supervision with transfers. She could walk short distances with contact guard assist and a rolling walker.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveradiofrequency ablation (RFA) of the facet joint nerves.You asked the Planto pre-approvethe facet RFA. You say that you have gotten this done in the past and it was helpful for your pain.The Plandenied your request. The Plansaysthere have been no recent diagnostic MBBs.The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joints is covered after two MBBs produce at least 80% pain relief. In this case, although you have had an RFA procedure in the past, you have not had one within the last year. Without a recent trial of diagnostic MBBs to confirm that the RFA will be effective, this cannot be covered.Therefore, we decided that the Plandoes not haveto pre-approveradiofrequency ablation (RFA) of the facet joint nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveContour brand diabetic test strips.You asked the Planto pre-approvethe Contour strips. You say that this should be approved.The Plandenied your request. The Plansaysa 90-day supply was approved in order to allow a transition to the preferred brand. After the 90-day supply is used, no further supplies from this brand will be covered.The Plan must follow Medicare rules. Medicare rules say that Plans are allowed to cover only specific brands of medical supplies as long as all medically necessary supplies are available. In this case, no documentation was submitted to show that this specific brand is medically necessary. Without documentation to support that the use of a preferred brand is medically inappropriate, the rules for coverage of the Contour strips have not been met.Therefore, we decided that the Plandoes not haveto pre-approveContour brand diabetic test strips.
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. The Plan denied your request. The Plan says IRF admission 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services and diagnostic testing provided on March 14, 2018 by an out of network (OON) provider.You asked the Plan to pay forphysician services and diagnostic testing. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 has network providers available who can provide 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 forphysician services and diagnostic testing provided on March 14, 2018 by an out of network (OON) provider.
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 enrollee needs LTACH care.The Plan denied your request. The Plan says LTACH care is not needed because the same level of care can be provided in the current setting as long as it is 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation, hemodialysis, surveillance laboratory studies with indicated transfusions, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.