Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an inpatient rehabilitation facility.
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 based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute rehabilitation). 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 IRF admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve the SNF care.
You asked the Plan to pre-approve SNF care. You say that the rehabilitation facility you are in wants to discharge you. You also say that it is not possible for you to be discharged and could be hazardous to your health. The Plan denied your request. The Plan says that an admission to a SNF for inpatient skilled rehabilitation services 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 SNF care. Our reviewer says that you meet the Medicare criteria for SNF care. Our physician reviewer found you do not have documented skilled nursing needs, but you do have documented skilled therapy needs. You appear to be functioning below your baseline. Our reviewer found that you have made some functional progress and it has not yet been shown that you have reached a new plateau in function. Our physician reviewer also found that daily skilled services are required to establish a maintenance program or to prevent deterioration 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the SNF care.
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 require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to be able to perform, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you need to be 100% before you go home because you live alone. The Plan denied your request. The Plan says the services you require can safely be received at a different setting such as home with home health care, in residential care or home with close follow-up with your doctor.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Retacrit 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 Aranesp. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has anemia of chronic kidney 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 step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve transcatheter aortic valve replacement (TAVR).

You asked the Plan to pre-approve the TAVR procedure. You say that you require this procedure as it is now your only option in order to be considered for liver transplantation. The Plan denied your request. The Plan says that you do not have aortic stenosis which is the only covered indication for the requested TAVR procedure.

The Plan follows Medicare rules. Medicare rules say that TAVR is covered by Medicare when the criteria listed in the Medicare rules section are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the TAVR procedure. Our reviewer says that the medical records support that the Medicare criteria for this procedure are met and that the procedure is medically reasonable and necessary for this patient. Our physician reviewer found the enrollee at issue has end-stage liver disease and end-stage kidney disease. Her liver transplantation is on hold due to the finding of mixed moderate aortic stenosis and severe aortic insufficiency seen on echocardiography and documented on cardiac catheterization. Based on her pre-transplant evaluation she requires aortic valve replacement prior to consideration of liver transplant. She was seen by the heart team including evaluations by cardiology and cardiac surgery, which put her at very high risk for open surgical valve replacement owing to combined liver and kidney failure along with a very heavily calcified aorta.

Although the enrollee has mixed valvular disease, she does have aortic stenosis which contributes at least some component to her symptoms. She is under the care of a multi-disciplinary heart team and has been evaluated by both cardiology and cardiac surgery and her surgical risk is prohibitive for open valve replacement due to her liver/kidney disease and heavily calcified aorta.

The patient requires liver transplant to improve any chance of long-term survival and quality of life. She cannot be listed to undergo this surgery with her current valvular heart disease. She requires aortic valve replacement, but she has absolute contraindications to open repair. She has a mixed picture of stenosis and regurgitation (though regurgitation is probably predominant) but given the component of aortic stenosis in her case, Medicare criteria are deemed to be 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 the TAVR procedure have been met. Therefore, we decided that the Plan has to pre-approve transcatheter aortic valve replacement (TAVR).

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: 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 you need LTACH admission for wound care. The Plan denied your request. The Plan says an LTACH admission 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 that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 

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 continued skilled nursing facility (SNF) care beyond October 2, 2021.

You asked the Plan to pre-approve the continued SNF care. You say that it is felt that continued care in the SNF setting is necessary. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services to maintain her condition.

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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, or other ongoing skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.

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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs).

You asked the Plan to pre-approve MBBs. You say that the requested MBBs are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested MBBs.

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 MBBs. Our reviewer says that the enrollee does not meet criteria for the requested MBBs. Our physician reviewer found the enrollee has chronic low back pain. She takes Lyrica and Tramadol for pain. She had a prior L5-S1 ALIF. The request is for diagnostic MBBs. The LCD specifically excludes MBBs at a level of prior surgery. 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 MBBs have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the facility you would like to be admitted to will be able to provide you with three hours of therapy every day, and they know your deficiencies. You also say that inpatient rehabilitation is what is best for you. The Plan denied your request. The Plan says your current medical and rehabilitation needs are not of the intensity and complexity that you must receive rehabilitation therapies three hours per day at least five days per week in a hospital setting. The Plan also says that you are improving rapidly and with steady exercise, appear to be recovering well.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. Our physician reviewer also found that there is not a reasonable expectation that you 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 the acute 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 rehabilitation before he can go home. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 be able to perform 15 hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs occupational and physical therapy along with medical management and oversight. The Plan denied your request. The Plan says it is not reasonable to expect that the enrollee will be able to fully benefit from the intensity of services of an IRF.

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 provided documentation indicates that the enrollee's is medically stable and does not have complex nursing or rehabilitation needs. The reviewer found that there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer also found that there is not a reasonable expectation that the 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. Specifically, the file shows that the enrollee would not benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Favorable

We decided that the Plan has to pre-approve Supartz FX (J7321).

You asked the Plan to pre-approve Supartz FX. You say that you are concerned that changing to Orthovisc after so many years of Supartz might lead to infection or adverse reaction. The Plan denied your request. The Plan says that the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 did not provide a copy of the applicable 2021 Evidence of Coverage for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve Supartz FX (J7321).

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.