Persius/hicric huggingface dataset:
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 cannot be adequately cared
for at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee is receiving
appropriate inpatient care and does not require transfer.
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 physician
reviewer found that the enrollee was admitted to the acute care hospital with sepsis, empyema, and bacteremia.
Her hospital course was complicated by lung collapse, mucus plugging, and bowel incontinence, requiring
wound care for stage 4 ulcer including debridement. She has chronic dysphagia requiring PEG tube feeds.
Recent notes show the enrollee as having been extubated successfully and antibiotic course has been
completed. She appears to be improving and should only require short-term additional acute care services that
can safely be received at the current facility. Transfer to LTACH is not medically necessary as it would not be
clinically advantageous compared to staying 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office
visits to be rendered by the 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 enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 was admitted for peripheral vascular disease of the lower extremity and had a below the knee
amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulation trial.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have a covered condition.

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 enrollee has chronic right foot pain. He takes Cymbalta and Gabapentin for the pain. He had a psychological evaluation and was cleared for a spinal cord stimulation (SCS) trial. Electromyography study shows peripheral neuropathy. The enrollee does not have an evidence-based indication for a SCS trail. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulation trial.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
You asked the Plan to pre-approve personal care services. You say that the services should be covered. The
Plan denied your request. The Plan says personal care services are not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code T1019 - personal care services,
per 15 minutes - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not
payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of personal care services have not been met. Specifically, the file shows that procedure code T1019 -
personal care services, per 15 minutes - has a Status Code of "I", indicating that this code is not valid for
Medicare purposes and is not payable. Therefore, we decided that the Plan does not have to pre-approve
personal care services, per 15 minutes (T1019).
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 you do 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 you may benefit from physical
therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity
setting such as in-home with 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 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's medical problems have left her at a
functional status below her baseline. The Plan denied your request. The Plan says the enrollee does not require
intensive medical treatment.
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 physician reviewer found
that the enrollee is at a moderate assist level for sitting up, minimal assist for walking using a rolling walker,
moderate assist for sitting down, maximal assist for toileting, and minimal assist for transfers. 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.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first.
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 Injectafer. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Infed
and Venofer first before they will approve the requested drug. The enrollee has not tried and failed the required
drugs. The documentation does not support that Infed and Venofer would likely be less effective, and/or would
likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer.
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 transfer to an IRF is 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 can be treated safely and effectively in a less intensive 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: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for total hip arthroplasty.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to
undergo this elective procedure.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the procedure is currently approved as an ambulatory procedure, and there is no
documentation provided indicating an expectation of a greater than 2 midnight stay. You are undergoing a
planned total hip arthroplasty. You are medically stable and have been provided medical clearance to undergo
this elective procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for an inpatient admission for total hip arthroplasty.
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. The Plan denied your request. The Plan says the enrollee has no skilled nursing or therapy needs that can only be provided on an inpatient basis.
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 physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, he was at a modified independent to standby assist level with functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. He does not meet 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment for a bed to be provided by
an out-of-network (OON) provider.
You asked the Plan to pre-approve durable medical equipment for a bed. You say that this equipment is
medically necessary. The Plan denied your request. The Plan says they have in-network providers available to
provide this equipment.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
durable medical equipment for a bed to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the endosteal implants. You say that you would like the implants covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal implant (D6010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that this is medically necessary. The Plan denied your
request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gradient compression wrap (A6545) for the enrollee.
You asked the Plan to pre-approve the wrap. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of qualifying wound or open venous stasis ulcers.
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 wrap. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based on the medical records provided there is no documentation that the enrollee currently has a qualifying wound or open venous stasis ulcers to meet the coverage criteria. As of 12/7/21, there are no open wounds, according to the records. 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 wrap have not been met. Therefore, we decided that the Plan does not have to pre-approve a gradient compression wrap (A6545) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant.
You asked the Plan to pre-approve Dexilant. The Plan denied your request. The Plan says Dexilant is a benefit
exclusion. The Plan also says that outpatient prescription drugs are not covered under the enrollee's Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexilant.
Benefits for Dexilant may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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