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

 We decided that the Plan does not have to pre-approve Hymovis (J7322).  You asked the Plan to pre-approve Hymovis. You say that you need this to walk. The Plan denied your request. The Plan says step therapy requirements have not been met.  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 Hymovis. Our reviewer says that the requirements for coverage of Hymovis have not been met. Our physician reviewer found the Plan requires a trial of Euflexxa, Supartz FX, Durolane, or Gelsyn-3 before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or have adverse effects for you.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital services (99223, 99497) provided on August 4, 2021.  You asked the Plan to pay for the hospital services. You say that this claim should not be denied as untimely because we are still in a public health emergency, and additional provisions apply. The Plan denied your request. The Plan says this claim was submitted more than one calendar year from the date of service. This claim is denied as untimely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the hospital services was not filed until August 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital services (99223, 99497) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (88112) rendered by an out-of-network (OON) provider on July 30, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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.  You are not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.  We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88112) rendered by an out-of-network (OON) provider on  July 30, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: 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 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. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different 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: 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 enrollee needs IRF services. The Plan denied your request. The Plan says that based on Medicare guidelines, the requested IRF services 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 that on review of the available records the enrollee does not meet CMS coverage criteria for an IRF admission. With her current medical stability, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs noted in the record.

The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy Her therapy needs can be easily and safely provided in a skilled nursing facility setting as she will not tolerate IRF level of intensity in therapies due to decreased activity tolerance and shortness of breath. IRF admission is not medically necessary based on lack of medical complexity and nursing needs and good functional level. The documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehabilitation needs can be safely provided in an alternate and low 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: 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 would like reconsideration because the enrollee is at high risk of complications following his operation and they require close medical observation. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the IRF 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 the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this member 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre.

You asked the Plan to pre-approve a FreeStyle Libre. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.

You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says the denial of authorization for Keytruda is correct, because you have used Keytruda longer than the recommended 24 months.

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 you do not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found you have received Keytruda without further disease progression since 2019. However, the record provided is insufficient to determine the mutation status or PDL-1 expression level of your tumor. The Food & Drug Administration (FDA) has not stated that the requested use of Keytruda is approved for your condition. The requested use is not supported by one of the major drug compendia or by clinical research appearing 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 use of Keytruda.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the intra-arterial ultrasound.

You asked the Plan to pre-approve the intra-arterial ultrasound. You say that you would like reconsideration because the documentation submitted supports the medical necessity of the requested service. The Plan denied your request. The Plan says that there is no evidence to support the use of intravascular ultrasound in arterial disease at this time.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the intra-arterial ultrasound. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the usage of intra-arterial ultrasound will be necessary according to the vascular surgeon to ensure proper location of stent material in this patient with severe peripheral vascular disease and gangrenous great toe. The Centers for Medicare and Medicaid Services has issued a letter approving the technique proposed by the surgeon. 

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 intra-arterial ultrasound have been met. Therefore, we decided that the Plan has to pre-approve the intra-arterial ultrasound.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 you did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of January 8, 2022. 

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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve authorization for a second opinion to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the authorization for a second opinion. You say that you would like reconsideration because you believe you would receive more effective treatment from this specialist. The Plan denied your request. The Plan says there are in-network providers available to render the necessary 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The provider at issue in this case is not a network provider with the Plan. 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 authorization for a second opinion. Our reviewer says that the documentation shows that your medically necessary care may be rendered in-network. Our physician reviewer found the Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of your condition. 

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 authorization for a second opinion have not been met. 

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the authorization for a second opinion. Therefore, we decided that the Plan does not have to pre-approve authorization for a second opinion to be provided by an out-of-network (OON) provider.
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 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 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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 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 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: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria. The
Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH admission does
not meet the requirements for approval.

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 that the enrollee appears to be improving and stable and should only require short-term
acute care services that they can complete at the current facility. The enrollee does not require services at
the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility. Therefore, LTACH transfer
will be considered not medically necessary as it would not be clinically advantageous.

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 LTACH services.