Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says the enrollee has not had an inadequate response to Retacrit for at least two months with appropriate dose adjustment.

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 Aranesp. Our physician reviewer found that in this case, the record indicates that the enrollee has anemia from chronic renal disease. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred drug, Retacrit. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic carpal tunnel release.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee presented with complaints of hand pain from carpal tunnel. The records do not contain physical examination results or testing consistent with the diagnosis. The records do not support that the requested procedure is reasonable or medically necessary for 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic carpal tunnel release.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided April 14, 2020.

You asked the Plan to pay for the inpatient care. You say that DRG 917 is supported. The Plan denied your
request. The Plan says the records do not support the billed DRG.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 917. 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 inpatient care. Our reviewer says that the billed DRG 917 is not supported by
the records. Our physician reviewer found the enrollee was noted to have a Glasgow Coma Score of 15, but
initially was reported to be lethargic. Vital signs were normal. Laboratory studies did not reveal metabolic
changes. A CT scan of the head was normal. The patient quickly improved. The provided does not establish the
presence of toxic encephalopathy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided April 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Imfinzi infusion for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says before this drug can be covered, it must be used for a medically-accepted indication.

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 the services. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee has a stage IV mixed adenoneuroendocrine gastric cancer, a GEPNEC. The Food and Drug
Administration has not stated that the requested drug is approved for this indication. The Medicare approved
cancer compendia do not contain a supportive citation, as defined by Medicare rules, requested drug is
approved for this indication. No literature from Medicare approved cancer journals was submitted to review.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Imfinzi infusion for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the rules for SNF care have not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you are a 92-year-old female with a past medical history including dementia, diabetes mellitus and hypertension who resides at a nursing facility at a custodial level of care. The medical record is reviewed in its entirety. At the time of transfer into the skilled nursing facility for isolation you were medically stable. You did not require any supplemental oxygen or medications specific for infection with the coronavirus. You did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. The member was noted to be at or near her functional and medical baseline. The member did not have any parental medication, complex wound care or nutrition given via a feeding tube. She was medically stable without any acute exacerbations of chronic medical problems. She can continue to receive care at a custodial level of care. Admission to skilled services was not medically necessary. The member required quarantine without skilled 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 health and recovery of the enrollee will be adversely affected if not approved. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval.

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 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bariatric surgery (43644).
You asked the Plan to pre-approve bariatric surgery. You say that this surgery is medically necessary. The Plan
denied your request. The Plan says that the coverage criteria for the requested surgery have not been met.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees
who have:
(1) a body mass index (BMI) of greater than or equal to 35;
(2) at least one co-morbidity related to obesity; and
(3) been unsuccessful with medical treatment for obesity.
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 bariatric surgery. Our reviewer says
that the requested surgery is medically necessary and reasonable. Our physician reviewer found that the
enrollee is a 66-year-old woman with a diagnosis of Morbid (severe) obesity due to excess calories. The
enrollee's medical history is also notable for mild obstructive sleep disordered breathing with obstructive events
associated with moderate to severe arterial oxygen saturation, reflux esophagitis, osteoarthritis, hyperlipidemia,
attention deficit disorder, and depression. The enrollee takes famotidine on an as needed basis. The enrollee has
tried Weight Watchers and a supervised weight loss program. Her BMI on July 9, 2021, was 40.75. The
enrollee underwent Preoperative Psychological Evaluation on April 9, 2021. The enrollee has a BMI greater
than or equal to 35, has at least one co-morbidity related to obesity, and has been previously unsuccessful with
medical treatment for obesity. The enrollee has co-morbid conditions associated with obesity, including
dyslipidemia, sleep apnea and osteoarthritis. The criteria for coverage have been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bariatric surgery have been met. Therefore, we decided that the Plan has to preapprove
bariatric surgery (43644).
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy services.

You asked the Plan to pre-approve the requested services. You say that this is the preferred treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed intensity-modulated radiation therapy (IMRT).

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 requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Therefore, the requested services are not considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has tried conservative treatment and had only minimal improvement. You state the enrollee also had lumbar epidurals with temporary relief. You state that although surgical decompression is the other treatment option, the enrollee does not want to have such a significant surgical procedure at this time when an U.S. Food and Drug Administration (FDA) approved minimally invasive treatment option is available. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve inpatient hospital care. The Plan denied your request. The Plan says the enrollee will not require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital care. Our physician reviewer found that a right reverse shoulder arthroplasty has been approved by the Plan. The enrollee has a history of obesity and hypertension. The enrollee is medically stable. The record does not show that the enrollee's necessary hospital care will span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 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 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you
presented to the hospital on September 15, 2021 with hip and back pain and inability to walk. You have been
working with physical therapy and are walking 30 to 50 feet with a rolling walker and assistance. You need
minimum assistance for transfers. There are no occupational therapy reports. The records state you are
medically stable for discharge. You have no skilled nursing needs. You have skilled therapy needs but do not
require skilled therapy on a daily basis. As a practical matter, you do 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
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five home health skilled nursing visits.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of hypertension, venous insufficiency, and lower extremity wounds and has been receiving home health nursing services since January 1, 2021. Based on the description of the wounds and the prior nursing treatments provided, there is no documentation that five further visits are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 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 five home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the device has not been shown to be safe and effective in long-term studies.

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 requested services. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show its safety and efficacy. Therefore, the requested device is not considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous stabilization device.
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 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital on September 15, 2021 with severe abdominal pain after a colectomy the prior week, shortness of breath, and fever. You were treated for congestive heart failure and stabilized. You are now medically stable with weakness. 

You have no complex medical issues that require physical medicine and rehabilitation supervision three times per week. You are at a functionally high level for bed mobility and transfers. You do not require an intensive therapy program in an IRF. The IRF 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 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.