Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee is still in the early part of their rehabilitation. You say that the enrollee has recently started to cooperate with therapy and is making progress. The Plan denied your request. The Plan says that the enrollee no longer requires daily skilled services.

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 the requested SNF care is medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The reviewer found that the enrollee is making progress with therapy and is not yet shown to have reached a plateau in function. The reviewer found that ongoing daily skilled services are reasonably required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Therefore, the reviewer found that the requested SNF care is medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 skilled nursing facility (SNF) care.

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 inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. The provided records show that you are medically stable and have been provided medical clearance to undergo this elective procedure which is typically ambulatory. There was no reported unstable condition. There is no documentation provided to support the expectation you will require a greater than a 2 midnight stay. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no literature or compendia to support this request.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab is FDA-approved as 1st line therapy in combination with FOLFOX or as a single agent after two or more lines or therapy. A combination with FOLFOX for this enrollee is not 1st line. In addition, this enrollee has progressed on prior PD-L1 therapy with Nivolumab and treatment with another PD-L1 inhibitor would not be indicated. This use is not supported by the medical literature. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from January 4, 2022, forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that the enrollee is not ready for discharge. The Plan denied your request. The Plan says under Medicare guidelines, the request is not medically necessary because the records received show that the enrollee's condition has improved and is no longer a threat to himself or others.
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 a continued inpatient psychiatric admission. Our reviewer says that a continued inpatient psychiatric admission from January 4, 2022, forward is not medically necessary. Our physician reviewer found that this enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from January 4, 2022, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from January 4, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found while you
may be able to safely operate the requested wheelchair, the specific requested wheelchair with power tilt
exceeds your medical need. The documentation does not reveal that you are at high risk for development of a
pressure ulcer, are unable to perform a functional weight shift, or utilize the intermittent catheterization for
bladder management, or need a power seating system to manage increased tone or spasticity. The face-to-face
visit notes that the enrollee can transfer independently and perform pressure relief.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair and accessories
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of the health problem.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for bone marrow aspirate 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on April 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a portable oxygen concentrator. You say that your oxygen saturation dropped dangerously low. You also say that your doctor ordered an oxygen concentrator for you quickly and closer to you, however, it appears that the oxygen concentrator was not in your network. The Plan denied your request. The Plan says according to Medicare, oxygen items or equipment purchased are not covered. The Plan also says that only the rental of oxygen equipment is covered.

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.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on April 27, 2021 by an out-of-network (OON) provider.
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. You say that the medical records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy services. The Plan says that no daily skilled nursing needs are noted. The Plan says that the enrollee's needs maybe met at a lower level of care.

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 reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the 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: 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 medical records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive the care needed in another setting.

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 recurrent falls and was discharged home on November 17, 2021 but has had continued episodes of falling. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and related supplies.
You asked the Plan to pre-approve a power wheelchair and related supplies. You say that the medical records provided support the need for the requested equipment. You say that they are also requesting a rural exception for out of network coverage because they are only 20 miles away from the enrollee's home. The Plan denied your request. The Plan says the notes do not show that the enrollee has any condition that causes problems walking. The Plan says that the requested durable medical equipment is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair and related supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the
enrollee has chronic lung disease with low back pain with functional deficits. The neurologic disorder causing the mobility limitation is not a congenital skeletal deformity, myopathy or neurological condition. The documentation does not indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder. 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 power wheelchair and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and related supplies.
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 IRF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 pneumonia. Your 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mobile dental services.

You asked the Plan to pre-approve mobile dental services. You say that you are on hospice and unable to leave home. The Plan denied your request. The Plan says mobile dental services are not covered.

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, mobile dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve mobile dental services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for the home infusion services.

You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct because
you self-administered this treatment. The Plan denied your request. The Plan says this copayment was charged
based on the Plan contract agreement and the claim submitted by the provider of the home infusion supplies.
The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and stated the QIC did not apply the correct contract language.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is cost share for home infusion therapy services. This would include those
the supplies that are prepared for self-administration. You have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation. Therefore, we decided the Plan does
not have to waive cost share charged for home infusion services provided from January 21, 2021, through
January 28, 2021.