Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 27, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on August 27, 2019.
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 was admitted to acute care on 2/4/20 following cardiac arrest, with return of spontaneous circulation achieved after 6 minutes of cardiopulmonary resuscitation. His hospital course has been complicated by sepsis secondary to pneumonia requiring pressors, severe encephalopathy, acute hypoxic respiratory failure and acute kidney injury.Based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs acute rehab nursing care. He may benefit from further physical therapy, speech therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on his current functional status as described above.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August
20, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records stating
exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided to the enrollee on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve JAK2 exon 12 mutation testing
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 JAK2 testing is covered for specific indications
only.
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 a diagnosis of
polycythemia vera and JAK2 V617F was detected on May 4, 2017 with both alleles showing mutation. Further
testing for the JAK2 exon 12 mutation is not needed, as it has not been demonstrated that repeating genetic
testing will impact the medical management of the enrollee in this case. The requested testing is 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 JAK2 exon 12 mutation testing
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Timolol Maleate 0.5% ophthalmic solution.You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual 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-approve the Timolol Maleate 0.5% ophthalmic solution.Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on December 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical package.We looked at the file and Medicare rules. The file shows that the services at issue were rendered within the 90-dayglobal surgical period for a surgical procedure performed on October 29, 2019. Payment for these services is included in the global surgical payment.Therefore, we decided that the Plan does not have to pay forthe physician services rendered  on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 210mg Evenity.
You asked the Plan to pre-approve the Evenity. You say that Evenity is medically necessary for the treatment
of the member's condition. The Plan denied your request. The Plan says this drug is not covered by the Plan.
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 Evenity. Our reviewer says that the
member has not tried and failed a trial of zoledronic acid or Prolia. Our physician reviewer found the requested
medication is deemed medically unreasonable and unnecessary 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 Evenity have not been met. Therefore, we decided that the Plan does not
have to pre-approve 210mg Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a tertiary provider.You asked the Plan to pre-approve an office visit with a tertiary provider. You say that this provider is convenient for you to get to.The Plan denied your request. The Plan says it is not necessary for you to see a tertiary provider.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 an office visit with a tertiary provider. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have diffuse joint pain, which has been treated with medications, injections and home exercise. While your cancer prevents you from being a candidate for joint replacement surgery, there appears to be nothing unusual about your joint pain. As such, treatment at a tertiary care center is not shown to be medically necessary or reasonable.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 office visit with a tertiary provider have not been met.Therefore, we decided that the Plan does not have to pre-approve an office visit with a tertiary provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 2, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that these services were medically necessary. 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 provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 22, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare 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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on January 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care provided on May 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision care. 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 for vision care provided on May 8, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you need theservices to get around better.The Plan denied your request. The Plan says there are no comorbidities that need a rehab physician on a 24/7 basis, and your therapy needs do not require an interdisciplinary approach.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require skilled physical therapy and occupational therapy, but you do not require treatment in an intensive rehabilitation therapy program. 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: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that it was discovered that the enrollee hashematoma of the brain and you want him to obtain rehab to improve his health. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for SNF care. The enrollee's needs could be met at a lower level of 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 askedour 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 care. Our reviewer says thatSNF care is medically necessary.Our physician reviewer found the physical therapy (PT) evaluation on March 2, 2020 documented that the enrollee has had a significant change in balance and function since developing the subdural hematoma. The enrollee could walk in place and take two steps forward and backward with a front-wheeled walkerand moderate assist. The physical therapy notes state that the enrollee will need a significant amount of further physical therapy to be safe for return home. Subacute rehab is strongly recommended. On March 2, 2020, it is documented in the occupational therapy (OT) note that the enrollee was currently requiring heavy assist with all mobility related activities of daily living. The enrollee was cooperative and motivated. The enrollee was following commands.There is a reasonable expectation that the burden of care will be reduced with such services with skilled nursing or skilled therapy services (or a combination of these services) on a "daily 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are requesting review for acute inpatient rehabilitation.The Plan denied your request. The Plan says the enrollee's care and treatment plan goals can be achieved in another setting such as at a skilled nursing facility.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 that based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically unstable. He may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on his current functional status and low tolerance for therapies and medical instability. We looked at this physician's review, the file, andMedicare 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued Home Health (HH) Physical Therapy (PT) services.You asked the Plan to pre-approvecontinued HH PT. You say that you would like additional HH PT visits.The Plan denied your request. The Plan says continued HH PT is not medically necessary.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 continued HH PT. Our reviewer says that continued HH PT is not medically necessary at this time. Our physician reviewer found the documentation does not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary. The documentation does not show that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary. Outpatient physical therapy appears to be appropriate 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 continued HH PT have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued Home Health (HH) Physical Therapy (PT) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for the treatment of the
member's condition. The Plan denied your request. The Plan says the records do not show that member is
receiving concomitant aromatase inhibitor therapy as adjuvant therapy.
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 Prolia. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support that the Prolia is safe and effective for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 21, 2019
to September 6, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not meet Medicare criteria for SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from August 21, 2019 to September 6, 2019.