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

We decided that the Plan does not have to pre-approve a right total hip replacement.
You asked the Plan to pre-approve a right total hip replacement. You say that the requested right total hip
replacement is medically necessary. The Plan denied your request. The Plan says the requested right total hip
replacement is not medically necessary.
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 a right total hip replacement. Our
reviewer says that the requested right total hip replacement is not medically necessary. Our physician reviewer
found the enrollee was being treated for unilateral primary osteoarthritis, right hip. She presented with a
multiple year history of right hip pain. There is pain in the groin and buttock region that is worse with increased
activity. Her pain is limiting her activities of daily living. She has difficulty sleeping at night due to pain. Exam
reveals tenderness over the greater trochanter. There is an antalgic gait noted. Flexion, Adduction, Internal
Rotation test is positive. Resisted straight leg raise is positive. The September 14, 2021, x-rays of the right hip
have conclusions of right hip degenerative joint disease. However, detailed documentation is not evident
regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures.
There is limited published, large-scale, long-term peer-reviewed literature that shows total hip replacement to
be indicated prior to trial and failure of conservative care measures. There is no compelling rationale presented
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore,
the request for a right total hip replacement is not medically reasonable or 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 a right total hip replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve a right total hip replacement.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opdivo.  You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your request. The Plan says the requested use is not supported.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Opdivo. Our reviewer says that the requirements for coverage of Opdivo have not been met. Our physician reviewer found monotherapy with Opdivo for gastric adenocarcinoma is not Food and Drug Administration-approved. It is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection.  You asked the Plan to pre-approve an epidural steroid injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is not a current physical exam.  The Plan must follow Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered medically reasonable and necessary when there is a history, physical examination, and concordant radiological image-based diagnostic testing supporting a covered diagnosis. The radiculopathy, radicular pain, or neurogenic claudication must be severe enough to greatly impact quality of life or function.  We looked at the file and Medicare rules. The submitted medical records do not include current imaging supporting the requested injection. The imaging provided is dated prior to surgical intervention. The physical exam also documents that the enrollee's pain is mild and is healing after surgery.      Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires long-term acute care and would be best served in an LTACH.  The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving slowly but should only require additional short-term acute care that can be safely administered at the current facility for additional weaning and for drain and wound management. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when the enrollee has completed treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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. You say that the enrollee's assisted living facility is unable to care for him in his current condition. You say that the enrollee has dementia and is unable to understand that his ankle is not weight bearing. You say that the enrollee is unable to transfer from bed to chair or walk on his own. You say that the enrollee's physical therapist and occupational therapist say that the enrollee is making progress and is a good candidate for SNF care in order to keep progressing his recovery.  The Plan denied your request. The Plan says the enrollee's condition is stable. The Plan says that the enrollee does not require complex daily skilled care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the enrollee received oral medications, had stable vital signs, and was alert with confusion. The enrollee received physical therapy and occupational therapy. The enrollee was at a moderate assist level for transfers. The enrollee required varying assist with activities of daily living. The enrollee remained non-weight bearing on his right lower extremity. There are no identifiable current skilled nursing facility needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 in the Medicare rules section. 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the request for out-of-network services does not meet the requirements for approval.
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 the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee chronic venous hypertension and lower extremity lymphedema that does extend to the abdomen. The record is inconsistent as to whether the enrollee has failed a basic device. The record does not document a medical rationale why the specific Tactile brand is required. The elements of the coverage criteria are not satisfied. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).  You asked the Plan to pre-approve Keytruda. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is not being used for a medically accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Keytruda. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. Furthermore, the use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has increased oxygen requirements and required transfusion for anemia. The enrollee requires acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.  You asked the Plan to pre-approve the compression stockings. You say that compression stockings are medically necessary for the enrollee due to her medical history of edema and venous insufficiency. The Plan denied your request. The Plan says the requested items are non-covered.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.     Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Cervical/Thoracic Facet Joint Block.  You asked the Plan to pre-approve a Cervical/Thoracic Facet Joint Block. You say that the requested Cervical/Thoracic Facet Joint Block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Cervical/Thoracic Facet Joint Block.  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 a Cervical/Thoracic Facet Joint Block. Our reviewer says that the enrollee does not meet criteria for the requested Cervical/Thoracic Facet Joint Block. Our physician reviewer found the enrollee's documentation does not describe functional limitations and includes an exclusion criteria of radiculopathy.  Therefore, the request is deemed not medically reasonable or 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 a Cervical/Thoracic Facet Joint Block have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cervical/Thoracic Facet Joint Block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from January 19, 2022, forward.  You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that this care remains medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 the continuation of inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 13, 2022, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety.  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 continuation of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from January 19, 2022, forward.
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 inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee will likely benefit from continued therapy to enhance his rehabilitation potential, but there is no evidence to suggest that this cannot be done safely in a lower 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 in the Medicare rules section.  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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve IRF care.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says that the clinical information provided did not indicate that the enrollee is able to participate meaningfully with at least three (3) hours of therapy services per day, that the enrollee requires physician evaluation at least three (3) times per week, or that the enrollee requires rehabilitation nursing services to be available 24 hours per day. The Plan states the request is being denied because the clinical information did not support the medical necessity for acute inpatient rehabilitation admission. The Plan states the enrollee's condition could be managed in a lower level of care.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied the services because they stated the enrollee did not need the care based on clinical information provided. It appears that the plan's contracted delegate was provided the records for this admission based on their denial and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pre-approve IRF 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.