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

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 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 based on review of the available records, the enrollee has debility from acute illness, is stable with no other acute medical issues and does not meet CMS coverage criteria for an IRF admission. With her current medical stability, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs noted in the record. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day, at least 5 days per week with multidisciplinary approach to daily therapy. Her therapy needs can be easily and safely provided in skilled nursing facility (SNF) setting. IRF admission is not medically necessary based on lack of medical complexity and nursing needs. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an 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 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely provided in an alternate and low intensity setting such as in 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. 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 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 Retacrit. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical
situation. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit.
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 an IRF admission is needed because the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says criteria for an IRF admission have not been met.

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 on review of the available records the enrollee is stable with no other acute medical issues and does not meet CMS coverage criteria for an IRF admission. With his current medical stability, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs noted in the record. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. His therapy needs can be easily and safely provided in a skilled nursing facility setting. An IRF admission is not medically necessary based on lack of medical complexity and nursing needs. The documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy and occupational therapy, his rehabilitation needs can be safely provided in an alternate and low intensity 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 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Velcade.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has small cell lymphoma transformed to plasmablastic lymphoma. He has an aggressive lymphoma and requires less aggressive therapy due to a poor performance status. The medical literature supports the use of Velcade in this case. In this rare cancer, there are numerous case reports and small studies supporting use. The services are therefore reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Velcade.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain with neurogenic claudication. The records indicate a normal neurologic examination. There is no documentation of acute injury. The requested test is being used to determine the need for neurosurgical consultation. The records do not support that the services are reasonable or medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be performed by an oral surgeon.

You asked the Plan to pre-approve oral surgeon services. You say that you went to an in-network dentist and were referred to an oral surgeon, and you are in extreme pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because services performed by an oral surgeon are not covered by the Plan.

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, the requested items or services are not among those covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve dental services to be performed by an oral surgeon.
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 IRF due to his complex medical
condition. The Plan denied your request. The Plan says the denial of 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
enrollee does require 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says services that can only be provided as an inpatient in a skilled nursing facility are not required.

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 admission. 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. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 12, 2022.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you were admitted to the SNF on December 29, 2021 with a fractured sternum following a car accident. As of January 12, 2022; you have no skilled nursing needs. You received skilled therapy but have reached your maximum level of function. You no longer requires skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the stance flexion special knee feature.

You asked the Plan to pre-approve the stance flexion special knee feature. You say that you would like reconsideration because the requested prosthesis is medically necessary. The Plan denied your request. The Plan says the requested part is unbundled from the approved knee

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has been approved for a prosthetic leg. the prosthetic leg includes knee prothesis which serves the same purpose as the stance flexion special knee feature. Therefore, we decided that the Plan does not have to pre-approve the stance flexion special knee feature.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires inpatient
care while waiting for a bed at a rehabilitation facility. The Plan denied your request. The Plan says there is no
medical necessity for an inpatient level of care.

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 for acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the enrollee presented to the emergency department and was admitted
under observation care. The enrollee's conditions were treated and uncomplicated. She was hemodynamically
stable on admission to the hospital and the treating physician suggested that she was stable enough to discharge
home. She did not require intravenous medications. The documentation did not show evidence that the enrollee
required hospital services that would likely cross 2 midnights due to low severity and low complexity.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Dalvance.

You asked the Plan to pre-approve Dalvance. You say that this is the most appropriate therapy for the enrollee.
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because
Dalvance is not medically necessary for the enrollee.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
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 Dalvance. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Dalvance. Our physician reviewer found
the Food & Drug Administration (FDA) has not stated that Dalvance is approved for the enrollee's condition.
The requested use 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 Dalvance have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Dalvance.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the enrollee will be treated with radiation therapy
while continuing maintenance with Keytruda. The Plan denied your request. The Plan says that the denial of
authorization for Keytruda is correct, because Keytruda is not approved for lung cancer that has progressed
after prior treatment with Keytruda.

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. Our reviewer says that the
enrollee meets criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is Food &
Drug Administration (FDA) approved for maintenance therapy in an enrollee with oligometastatic disease
treated with radiation therapy and is a standard of care. Keytruda is otherwise safe and effective and medically
reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve
use of Keytruda.

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.