Persius/hicric huggingface dataset:
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 the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of SNF 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee had uncomplicated wound care to ulcers on her left buttocks and sacrum. The enrollee received physical therapy and occupational therapy. By the dates in question, the enrollee was at a supervision to contact guard assist level with functional mobility including gait to 60 feet. the enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. 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 the 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ilumya (tildrakizumab-asmn) treatments.  You asked the Plan to pre-approve the Ilumya treatments. You say that it is felt that this drug is necessary and that other drugs should not be required. The Plan denied your request. The Plan says the preferred drugs have not been trialed prior to this request for Ilumya.  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 the Ilumya treatments. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy guidelines. Our physician reviewer found the Plan requires a trial of Remicade or Inflectra AND Stelara before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 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 Ilumya treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (tildrakizumab-asmn) treatments.
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 your records show that it is not reasonable to expect that you will be able to fully benefit from the intensity of services of an IRF. The Plan states you do not require physician supervision by a rehabilitation doctor at least three (3) days per week. The Plan states you do not require an intensive and coordinated interdisciplinary approach to your rehabilitation and your rehabilitation is not complex. The Plan states it is not reasonable to expect that you would be able to actively participate safely in three (3) hours of therapy five (5) days a week or fifteen (15) hours of therapy a week, you are very weak and unsteady, you have problems with confusion, described as lethargic and then emotional two (2) days ago. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility or home with home health services.  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 are medically stable and do not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With your current medical stability, and no other medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehabilitation nursing needs. At the current functional level as described above, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and no nursing needs. Document does not support the necessity for admission to IRF. While you will benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  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: 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 you do not require an intensive rehabilitation program. The Plan states physical therapy at a skilled nursing facility may be covered if requested.  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 are medically stable and do not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With your current medical stability, and no other medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute rehabilitation nursing needs. At the current functional level of dependency, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. With morbid obesity, severe debility, with right upper extremity (RUE) weight bearing restrictions from a fracture, your will not make a significant functional progress in a specified (predicted) period of 7-10 days in an IRF. IRF admission is not medically necessary based on lack of medical complexity and no nursing needs. Document does not support the necessity for admission to IRF. While you will benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  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 pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the documentation provided supports the need for SNF care. The Plan denied your request. The Plan says the care needed can be provided in the home or by an unlicensed caretaker.  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 the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy. The enrollee was at a minimal assist to dependent level for functional mobility. The enrollee required varying assist with activities of daily living. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit with a specialist to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit with a specialist. You say that your provider says he does not believe your condition can be treated by him or any of the staff members without an accompanying fusion. You also say that you do not understand why the Plan denied the services if the provider does not offer the services. The Plan denied your request. The Plan says they will not refer you to a non-Plan specialist for treatment because these services are available within the Plan.  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 an office visit with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the podiatrist you went to said you have a condition called pes cavus. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 based on IRF criteria. The Plan states the enrollee could receive care in another setting and they could review alternate settings if requested such as a skilled nursing facility, outpatient setting or home health care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.     Our physician reviewer found the enrollee is medically stable with no complications and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With the enrollee's current medical stability, and no other medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute rehabilitation nursing needs. At the current functional level as described above, the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical complexity and no nursing needs. Document does not support the necessity for admission to IRF. While the enrollee will benefit from continued physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF).  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: 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 LTACH would be the ideal setting for the enrollee's continued care. The Plan denied your request. The Plan says the enrollee's needs can be met in the current facility.  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 facility. 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 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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the physician office visit (99491).  You asked the Plan to pay for an office visit. You say that the services should be covered, and the denied claim should be reprocessed. The Plan denied your request. The Plan says that the denial is correct as the authorization on file does not match what was billed.  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 remittance advice for this claim shows that the Plan had an authorization on file for this provider but that the specific services rendered were not authorized. The Plan did not send us a copy of the authorization, so it is not possible to confirm that the services rendered are in excess of what was authorized. Since services from this provider were authorized based on the Plan's own documentation, we find that the denial is not substantiated. Therefore, we decided that the Plan has to pay for the physician office visit (99491).   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the enrollee would be a good candidate for custom orthotics for future prevention of injury and pain. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotic.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where he 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 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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that 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 medical records provided the enrollee's medical conditions do not meet the Medicare criteria for complexity which would require care in a long-term acute care hospital (LTACH). Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as a sub-acute rehabilitation facility or a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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.