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

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care such as 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 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 long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for transfer to an LTACH. The enrollee cannot be adequately cared for at a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 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 that there is no documentation provided indicating medical necessity for LTACH services. 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (83036) rendered by the out-of-network (OON) provider on May 25, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.   

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (83036) rendered by the out-of-network (OON) provider on May 25, 2021.
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 meets criteria for an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: 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 requires an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: 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. The Plan denied your request. The Plan says it is not medically reasonable to expect the enrollee to participate in daily intensive therapies.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was hospitalized with pneumonia and acute respiratory failure exacerbation, treated with antibiotics and steroids. At the current functional level, he does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.

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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve video head impulse testing for the enrollee.  

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence in the peer-reviewed literature that video head impulse testing has proven beneficial outcomes.  

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the role of video head impulse testing in the evaluation of vertigo has not been well-established. It has not been demonstrated how this testing will impact the management and outcome of the enrollee.       

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve video head impulse testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the fluid swing and stance knee-shin system (L5828) and adjustable stance flexion feature (L5845) for use with a lower limb prosthesis.  

You asked the Plan to pre-approve the requested prosthetic components. You say that it is felt that this type of knee meets the enrollee's needs. The Plan denied your request. The Plan says without documentation from a provider without a direct financial interest showing that the enrollee is at functional level 3, this cannot be approved.  

The Plan follows Medicare rules. Medicare rules say that the type of knee used for a prosthesis depends on the functional level of the enrollee. The requested knee requires a level 3 ambulator.     

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested prosthetic components. Our reviewer says that the requested prosthetic components are not shown to be medically reasonable and necessary in this case. Our physician reviewer found documentation provided stated that he was at a level 3 of activity; however, this was not substantiated objectively in the patient's physician's documentation to support this device. Therefore, without sufficient support made for this device, it will be considered not medically necessary at this time based on the provided documentation.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested prosthetic components have not been met. Therefore, we decided that the Plan does not have to pre-approve the fluid swing and stance knee-shin system (L5828) and adjustable stance flexion feature (L5845) for use with a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Darbepoetin alfa injection for the enrollee.  

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says for these injections to be covered in the setting of nondialysis-dependent chronic kidney disease, other causes of anemia (including bleeding and iron deficiency) need to be addressed.  

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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the documentation indicates that the enrollee is noted to have had a recent gastrointestinal hemorrhage with a linear ulcer found at the distal esophagus. The most recent laboratory values reveal anemia with a low iron level, low transferrin saturation and low ferritin level. The Medicare guidelines and Medicare-approved compendia state that for ESAs to be covered in the setting of non-dialysis-dependent chronic kidney disease, other causes of anemia (including bleeding and iron deficiency) need to be addressed. To support the medical necessity of ESA administration, there must be documentation of adequate iron stores. This has specifically been quantified as having a transferrin saturation greater than 20% and/or serum ferritin levels greater than 100 ng/ml. The enrollee has values of 16% and 61 ng/ml, respectively. There is no documentation of iron replacement efforts in the clinical provided with this request. The review has determined that the documentation does not support that the injection is medically reasonable, necessary, safe, or effective.  

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Darbepoetin alfa injection for the enrollee.
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 IRF care is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for immunofluorescence (88350-59) provided on June 17, 2021.  

You asked the Plan to pay for immunofluorescence. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the record shows that all units of 88350 were performed in the same encounter and on the same organ. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for immunofluorescence (88350-59) provided on June 17, 2021.
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 this admission is medically necessary. The Plan denied your request. The Plan says the criteria for an admission to a long-term acute care hospital 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 appears to be improving and near baseline requiring only short-term additional acute care services that can safely be administered 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron tablet 8mg 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 this drug is self-administered.  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 Ondansetron tablet 8mg for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Sandostatin Lar Depot 20mg vial for the enrollee.  You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of an FDA-approved indication for this drug.  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 this is medically necessary.. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review has determined that the documentation does not support that the requested drug is medically reasonable and necessary for the enrollee. The documentation does not support that the requested drug is safe and effective 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 this is medically necessary. have not been met. Therefore, we decided that the Plan does not have to pre-approve Sandostatin Lar Depot 20mg vial for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Neupogen (J1442).  You asked the Plan to pre-approve Neupogen. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested treatment have not been met.  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 Neupogen. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is being treated with Abraxane for pancreatic cancer. This regimen has an incidence of less than 10% febrile neutropenia. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neupogen have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Neupogen (J1442).