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

We decided that the Plan does not have to pre-approve a stress transthoracic echocardiogram (TTE) 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 a stress TTE is covered when specific 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has some coronary risk and one episode of atypical chest pain. There is no documentation of an abnormal cardiovascular physical exam, an abnormal electrocardiogram, or inability to adequately ambulate on a treadmill. In this circumstance, coverage criteria for stress echocardiography or a resting echocardiogram are not met since there is no documented covered indication for the procedure. The stress TTE is not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a stress transthoracic echocardiogram (TTE) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo 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 services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has presumed advanced non-small cell lung cancer (NSCLC). His PDL1 expression is zero percent. Opdivo is FDA-approved for the treatment of metastatic NSCLC that has progressed on or after platinum-based chemotherapy. There is no documentation of the enrollee's prior treatment; therefore, Opdivo is not reasonable or 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 not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo for "the enrollee".
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 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 IRF admission iscovered 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 records show that you were admitted to the hospital on December 26, 2019 with shortness of breath and cough. You were managed for chronic respiratory failure and pneumonia and are now medically stable. You need assistance with transfers and basic activities of daily living. You have no complex issues that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitationcare. You may benefit from further therapy but do 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-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 for "the beneficiary".You asked the Plan to pre-approvethe LTACH 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. 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 is currently undergoing treatment at an acute care hospital(ACH) for a brain abscess following recent cranial surgery. The enrollee underwent evacuation of the abscess and is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. The enrollee is being allowed to take orals and is participating in rehabilitative services. 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.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 for "the beneficiary".
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 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 IRF admission iscovered 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 records show that you were admitted to the hospital on January 4, 2020 with a urinary tract infection and altered mental status. You need assistance with walking 80 feet with a walker and moving from sitting to standing. You are medically stable with no complex needs that require the intensity of services in an IRF. You may benefit from further therapy but do 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the IRF would be a better choice for the enrollee.The Plandenied your request. The Plansaysthe criteria for IRF care are not met in this case.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 admitted to a SNF on 12/18/2019 following an admission for amputation due to a deep vein thrombosis. IRF care is felt to be needed. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 Plandoes not haveto 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).You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are notmedically 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 intravenous antibiotics, telemetry monitoring, intravenous cardivascular infusions, surveillance laboratory studies, specialty consultations, wound 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 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveroutine transportation to an appointment 280 miles away.You asked the Planto pre-approvethe 280 miles trip. You say that you need to make it to this appointment and cannot drive.The Plandenied your request. The Plansaysyour plan does not cover routine transportation to locations more than 50 miles away.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. ThePlan covers routine transportation up to 50 miles per one-way trip.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 the 280 miles trip have not been met.Therefore, we decided that the Plandoes not haveto pre-approveroutine transportation to an appointment 280 miles away.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/mL for the enrollee.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Prolia. Our reviewer says that the
documentation does not support that the enrollee has tried and failed the required drugs. Our physician
reviewer found the enrollee has osteoporosis and history of compression fractures. The enrollee is on calcium
and vitamin D supplementation. The enrollee has a history of gastroesophageal reflux disease (GERD). The
provided medical records do not indicate that the enrollee has tried and failed the required drugs. While the
provided medical records do indicate that oral bisphosphonate treatment would likely have adverse effects for
the enrollee due to GERD but this does not apply to zoledronic acid. Therefore, the enrollee does not meet
criteria for the requested drug.
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 60 mg/mL.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require the compression stocking after adoctor told you to wear it for arm swelling and a history of a blood clot.The Plan denied your request. The Plan says that compression stockings identified with code A6549 are not covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services beyond January 6, 2020.You asked the Plan to pre-approvethese services. You say that the enrollee needs more physical therapy.The Plan denied your request. The Plan says the continued services are not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for a lower gastrointestinal (GI) bleed. She had stable vital signs and was monitored for pain and falls. She received physical and occupational therapy in the SNF and needs assistance with functional mobility, including gait to 20 feet with a walker. She needs varied assistance with activities of daily living. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.We looked atthis 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-approvecontinued skilled nursing facility (SNF) services beyond January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of a chest wall respiratory sensor (Inspire procedure).You asked the Plan to pre-approveInspire procedure. You say that this procedure is medically necessary for you, and the Plan's denial does not specifically apply to this procedure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that the Inspire procedure is not covered by Medicare at this time. We looked at the file and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of Inspire procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of a chest wall respiratory sensor (Inspire procedure)
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. The Plan denied your request. The Plan says that the enrollee's continued care could be provided at home/outpatient setting or long term care facility (with a restorative nursing program) with therapy/nursing services through Medicare Part B if necessary.
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 the enrollee's 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 for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to approvecontinued skilled nursing facility (SNF) services after January 1, 2020 for "the beneficiary".You asked the Plan to approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the continued services are not medically necessary.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 1, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to approvecontinued skilled nursing facility (SNF) services after January 1, 2020 for "the beneficiary" .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 ifthere 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 Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs SNF care to continue treatment. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on October 21, 2019 with hydrocephalus with need for shunt revision. She received oral medications and had stable vital signs. She received physical and occupational therapy in the hospital and is inconsistently following commands. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crown x4 (D6740) and prosthodontics - fixed
pontic x4 (D6245) to be provided by the doctor.
You asked the Plan to pre-approve the dental services. You say that the records provided should support the
necessity of the services in dispute. The Plan denied your request. The Plan says this request is not medically
necessary.
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. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's dental record and radiographs indicate that there are multiple missing
maxillary teeth bilaterally. There was no documentation that the enrollee could not tolerate a removable partial
denture replacing all the missing teeth which would adequately restore the masticatory function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve retainer crown x4 (D6740) and prosthodontics - fixed pontic x4 (D6245) to be
provided by the doctor.