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 clinical information provided supports the need for IRF care.The Plan denied your request. The Plan says the clinical information does not demonstrate that the enrollee needs daily supervision of a physician and nurse or that multidisciplinary therapies are needed.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 does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer found that the enrollee's care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-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 enrollee would be better served with her clinical complexities in an LTACH setting. You say that the enrolleeis at high risk for decline and more complications without the care being requested. You say that a skilled nursing facility would not be able to provide the level of care the enrollee requires.The Plan denied your request. The Plan says the current acute care hospital can provide acute care services until the enrollee's condition allows transfer to a lower level of care, such as a skilled nursing facility, home health care, nursing home, or home.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 medical records show that an acute care hospital is able to provide all of the services the enrollee requires. Our physician reviewer found that the enrollee is receiving the necessary services and is at an appropriate level of care in the 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.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer. The PET scan is being requested for initial treatment strategy and staging. PET scans are denied for initial staging and treatment strategy for prostate cancer. The 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an evaluation for a kidney transplant.
You asked the Plan to pre-approve an evaluation for a kidney transplant. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's use of marijuana is not addressed in the documentation.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 an evaluation and kidney transplant. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the patient has been screened and medical record reviewed (including daily marijuana use) and the patient is a judged to be a candidate for evaluation for suitability for transplant. Marijuana use is not an absolute contraindication for renal transplantation. It is taken in consideration by the transplant center and its use will be part of complete physical, psychological, and social evaluation for suitability for transplant. The patient was open about use of marijuana and the center did not mention it as a barrier or contraindication in records provided. Workup should proceed for kidney transplantation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an evaluation and kidney transplant have been met. Therefore, we decided that the Plan has to pre-approve an evaluation for a kidney transplant.
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 to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has met the 100 day SNF benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from July 9, 2019 to December 23, 2019. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvelumbar epidural injections (64483).You asked the Planto pre-approvelumbar epidural injections. You say that this is medically necessary.The Plandenied your request. The Plansays the enrollee has not failed four weeks of non-surgical, non-injection care and does not meet any of the exception requirements.The Plan follows Medicare rules. Medicare rules say that lumbar epidural injectionsare covered only when the above listed criteria are met.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 lumbar epidural injections.Our reviewer says that the enrollee has not met Medicare criteria for the requested injections. Our physician reviewer found there is no documented pain from Herpes Zoster. There is no evidence of a significant functional loss at work or home. There is no evidence of severe pain unresponsive to outpatient medical management or inability to tolerate non-surgical, non-injection care due to co-existing medical conditions. There is no evidence that the prior successful injections for same specific condition gave relief of at least 3 months' duration. The documentation indicates the patient's pain initially radiated into his left hip and down the left leg and that the patient was feeling much better with improved left hip pain from therapy. The documentation does not support that the patient has therefore failed four weeks of non-surgical, non-injection 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 lumbar epidural injectionshave not been met. Therefore, we decided that the Plan does not have to pre-approvelumbar epidural injections (64483).
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-approvetheLTACH 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's ongoing care needs include surveillance laboratory studies, intravenous antibiotics, wound vacuum care, 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 conditionof 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.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services beginning January 6, 2020.You asked the Plan to pre-approvethese 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 inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was involuntarily admitted to the hospital on December 24, 2019 with major neurocognitive disorder with behavioral disturbance. It is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing dangerousness to self or others, no auditory or visual hallucinations,and no abnormal behaviors. He is not showing suicidal or homicidal ideation. It does not appear that active treatment is taking place. He is compliant with treatment. The requested 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services beginning January 6, 2020.
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 SNF services. The Plan denied your request. The Plan says that you appear to be at baseline function.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does 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-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond
January 5, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that you feel that you need to remain in
the SNF for a longer period. The Plan denied your request. The Plan says you no longer require daily skilled
services to meet your needs.
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 continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 86 year
old male was admitted to the hospital on 12/2/2019 due to urinary retention and acute renal insufficiency. He
was admitted to the SNF on 12/9/2019. From a nursing perspective, the beneficiary received oral medications
and had stable vital signs. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF.
By the dates in question, he was at a stand by assist to contact guard assist level with functional mobility
including gait to 200 feet with a rolling walker. The beneficiary required varying assist with ADLs from set up
to contact guard assist.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZioptan.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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-approveZioptan.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete mandibular dentures (CPT D5120).
You asked the Plan to pre-approve the complete mandibular dentures. You say that the enrollee needs a complete dentures set due to her old dentures having broken in half. The appellant says that the enrollee cannot wait until her new benefit for dentures, since she cannot eat and has difficulty talking. The Plan denied your request. The Plan says your benefit for dentures is currently exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the coverage for dentures is limited to one set every five years. The records show that the plan provided coverage for a set of dentures provided to the enrollee on December 11, 2018. This means that five years has not passed since the last set of dentures were covered and, therefore, the benefit for dentures is exhausted. Therefore, we decided that the Plan does not have to pre-approve complete mandibular dentures (CPT D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee.
You asked the Plan to pre-approve Prednisone. You say that the enrollee has had a severe headache which has not responded to her conventional medication. The Plan denied your request. The Plan says Prednisone to be taken at home is not covered under the Part B benefit.
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 Prednisone for the enrollee.
Benefits for Prednisone 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 30, 2019 for influenza, chronic obstructive pulmonary disease (COPD) exacerbation, sepsis, and hypotension. Her medical status improved and she is now afebrile and non-toxic. She is stable and needs minimal assist with self-care and transfers. She has no complex medical or nursing issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to neurosurgery for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has new onset of back pain with left-sided radiculopathy. He is status post L3-S1 instrumented fusion with lumbar laminectomy on March 12, 2018 with resolution of lower extremity symptoms. Given the enrollee's significant surgical history and new onset of neurologic symptoms, referral to a neurosurgeon is indicated. The referral is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a referral to neurosurgery 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 to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMorphine Sul Tab 30mg ERYou asked the Plan to pre-approvethe 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-approveMorphine Sul Tab 30mg ER