Persius/hicric huggingface dataset:
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 continues to require daily
doctor visits with specialty consultations. You state transfer to the LTACH is the most clinically appropriate
and cost-effective setting to continue the enrollee's ongoing care. The Plan denied your request. The Plan says
the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH.

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 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 they are 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 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy.

You asked the Plan to pre-approve Ubrelvy. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Ubrelvy.

Benefits for Ubrelvy 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 acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 was admitted for respiratory failure, Coronavirus pneumonia, and pulmonary embolism. 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, 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. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 25, 2021, to March 31, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive skilled care during the date of service in this case.
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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the SNF care have not been met. Specifically, the file does not indicate that the enrollee received skilled care during the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 25, 2021, to March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the life sustaining ambulance situation (A0422) provided from December 18, 2020, to April 28, 2021.

You asked the Plan to pay for the life sustaining ambulance situation. You say that the enrollee was in poor health, wheelchair bound, and the only safe way for her to return from the hospital was in an ambulance. The Plan denied your request. The Plan says the charge for this service is not payable by the Plan because this service is part of another service provided to the enrollee for which reimbursement was or will be considered.

The Plan must follow Medicare rules. Medicare rules say that the ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neckboards, and inflatable leg and arm splints. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the life sustaining ambulance situation have not been met. Therefore, we decided that the Plan does not have to pay for the life sustaining ambulance situation (A0422) provided from December 18, 2020, to April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there was no indication that you could not participate in treatment at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you do not have dangerousness to self or others, auditory or visual hallucinations, delusions and are not showing any behavioral issues. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 8, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that melanoma risk stratification molecular testing is covered for the indications established in the applicable LCD. 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 testing. Our reviewer says that the requested genetic testing is not medically reasonable and necessary in this case. Our physician reviewer found that the melanoma was removed on April 8, 2021, and the genetic test was requested. Per the analysis supplied, the likelihood of sentinel lymph node biopsy (SLNB) positivity for this patient was 2.2 percent, which does not meet the standard for approval for the test. The genetic testing in this case is not medically reasonable and necessary according to the coverage criteria established in the LCD. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings (A6531, A6549) for the enrollee.

You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of an active venous stasis ulcer.

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 stockings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not show an active venous ulcer to help justify this request and meet the criteria for such. 

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 stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve compression stockings (A6531, A6549) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair (E1038).
You asked the Plan to pre-approve a transport chair. You say that the enrollee's knees are now bone on bone and he has vascular and cardio issues that makes it painful and difficult for him to get around or go to medical appointments and a transport chair is needed. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria and the requested transport chair is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a transport chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has left shoulder pain, diabetes, coronary artery disease, and hypothyroidism recently reporting difficulties with walking and transfers. The provided documentation, however, did not
clearly show or state that they had failed use of a cane or walker in the home or that their home would facilitate
a wheelchair for basic functions in the home. Therefore, this request for a transport wheelchair does not meet
criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a transport chair have not been met. Therefore, we decided that the Plan does
not have to pre-approve a transport chair (E1038).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are weak and need rehabilitation to move around again. The Plan denied your request. The Plan says your records do not show that you need to be seen by a rehabilitation doctor at least three times a week or require the care of an intensive team. The Plan states you require some assistance with mobility and daily activities. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.

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. You were admitted for respiratory failure and congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy combination of Keytruda, Carboplatin,
Paclitaxel, and Ondansetron.
You asked the Plan to pre-approve Keytruda, Carboplatin, Paclitaxel, and Ondansetron. You say that the
enrollee has recurrent disease and is concerned it will involve other organs. The Plan denied your request. The
Plan says the denial of authorization for this drug combination is correct, because this is not being requested for
a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Keytruda, Carboplatin, Paclitaxel, and
Ondansetron. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested
chemotherapy combination. Our physician reviewer found the requested use of Keytruda, Carboplatin,
Paclitaxel, and Ondansetron is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis.
This is only used if PDL1+ and no PDL1 is done. This combination 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, Carboplatin, Paclitaxel, and Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy combination of Keytruda, Carboplatin, Paclitaxel, and Ondansetron
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (procedure code J7999) provided to the
enrollee on March 23, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code J7999-KD (1 unit) remains not
supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code J7999 is "Compounded drug, not otherwise classified."
We asked our coder 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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the documentation does not support a
compounded drug, and does not include documentation to confirm the units billed. The documentation should
be clear regarding treatments given. An example would be a pharmacy compounding sheet to document
medications and units to be billed.
We looked at this coder'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 pay for physician services (procedure code J7999) provided to the enrollee on March 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus.
You asked the Plan to pre-approve Tacrolimus. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Tacrolimus.
Benefits for Tacrolimus 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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. 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 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 rehabilitation therapy program. 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.