Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean automatic blood pressure monitor (A4670).You asked the Plan to pre-approvean automatic blood pressure monitor. You say that the Plan's EOC states that enrollees must pay 20% of the Medicare-allowed amount for monitors.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature because it provides a preventive service. This item is available to the general public and would be helpful even to those who are not sick or injured. We also note that the Plan's EOC only discusses coverage of blood sugar monitors.Therefore, we decided that the Plan does not have to pre-approvean automatic blood pressure monitor (A4670
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoes (L3216, L3217, L3215).
You asked the Plan to pre-approve orthopedic shoes. You say that you need these shoes because you have back problems. The Plan denied your request. The Plan says these shoes are not covered for your condition.
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 orthopedic shoes (L3216, L3217, L3215).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that the shower chair is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of area aide services.
You asked the Plan to pre-approve out of area aide services. You say that you want to visit relatives and need an aid for 2 months. The Plan denied your request. The Plan says the services have not been ordered by your physician and are not skilled in nature.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 out of area aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve out of area aide 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 you are a fall risk with damage to your hip. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the abdomen and pelvis.
You asked the Plan to pre-approve CT scan. You say that this CT scan will help the enrollee in cancer staging so she can move on with her treatment. The Plan denied your request. The Plan says that the denial of authorization for this test is correct, because this CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has invasive ductal carcinoma of the breast which is clinical stage 1B. A referenced previous CT scan was performed non-contrast for nephrolithiasis. The liver functions are normal. The enrollee has debilitating multiple sclerosis with chronic pain. Chronic pain will result in unreliable physical examinations due to distracting pain. The requested CT scan in this clinical scenario is medically reasonable and 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the abdomen and pelvis.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Apligraf skin substitute wound treatments.
You asked the Plan to pre-approve the treatments. You say that this is medically necessary. The Plan denied your request. The Plan says that the wound is not protected from trauma.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the treatments. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the wound does not heal and may lead to osteomyelitis. 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 treatments have been met. Therefore, we decided that the Plan has to pre-approve Apligraf skin substitute wound treatments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are interested in regaining your independence to prepare for transition to a prosthesis. You say that you have two more home physical therapy visits left and that is not going to be intensive enough to ensure you are prepared for the prosthesis. The Plan denied your request. The Plan says based on Medicare guidelines, an IRF admission from home does 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 based on the limited documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours of therapy per week. 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 an 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. The Plan denied your request. The Plan says the enrollee does not need an intensive team to get back to baseline.
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 admitted to the acute hospital for surgical repair of hip fracture after a fall. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 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 Reblozyl.

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. 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 not medically necessary. Our physician reviewer found the enrollee has high-risk myelodysplastic syndrome. The National Comprehensive Cancer Network (NCCN) guideline for Reblozyl in Myelodysplastic Syndromes states that Reblozyl is used in low-risk disease. The Reblozyl is not reasonable or medically necessary or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
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 molecular pathology procedures are covered when specific criteria are met. 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 records show that you have a diagnosis of mitochondrial myopathy and muscular dystrophy. Your provider has requested genetic testing to include exome sequence analysis and whole mitochondrial genome sequencing. The records do not support that the results of the testing would directly impact your treatment or management; therefore, the testing 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 genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for a total arthroplasty.
You asked the Plan to pre-approve the inpatient admission. You say that the inpatient stay is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 the inpatient admission. Our reviewer says that the documentation does not support that the criteria for an inpatient stay are met in this case. Our physician reviewer found the enrollee's condition is stable. The total shoulder arthroplasty may be performed safely with only an observational stay. 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 inpatient admission have not been met. Please note the plan has approved the procedure to be performed in the outpatient setting. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for a total arthroplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have osteoporosis or a history of a fracture.
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 Prolia. Our physician reviewer found that the requested use of Prolia is not FDA-approved for the enrollee's diagnosis. The enrollee has osteopenia and is not on an aromatase inhibitor. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

e decided that the Plan does not have to pre-approveSilodosin capsules.You asked the Plan to pre-approveSilodosin. You say that the enrollee has failed other medications.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.The Plan must follow Medicare rules. The rulessay 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-approveSilodosin capsules.Benefits for Silodosinmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PBT (CPT code(s): 77525, G6002, 77387), for the enrollee.

You asked the Plan to pre-approve the PBT. You say that the services are necessary. The Plan denied your request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than the type of treatment the Plan can approve. The Plan states this type of treatment is called IMRT (Intensity-Modulated Radiation Therapy) and this type of treatment changes the shape and strength of the beams during treatment. The Plan states IMRT would be approved if requested.

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 PBT. Our physician reviewer found the enrollee has non-metastatic prostate cancer. The radiation oncologist has reviewed the available treatment options. The treating physician has over ninety (90) publications demonstrating data collection and analysis experience. Normal tissue histograms have not been provided to demonstrate improvement with a proton beam therapy plan. The elements of the coverage determination 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 the PBT have not been met. Therefore, we decided that the Plan does not have to pre-approve PBT (CPT code(s): 77525, G6002, 77387), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvere-cementing a cast or prefabricated post and core (D2915) for teeth #8 and #10.You asked the Plan to pre-approvere-cementing a cast or prefabricated post and core. You say that this service is medically necessary for these teeth.The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan's supplemental dental benefit.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.Therefore, we decided that the Plan does not have to pre-approvere-cementing a cast or prefabricated post and core (D2915) for teeth #8 and #10
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve ipratropium-albuterol.
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 chronic obstructive pulmonary disease (COPD). The requested drug is indicated for the treatment of COPD for patients on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator. The enrollee has COPD and is being prescribed for the FDA-approved indication. The services are 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 ipratropium-albuterol.
Local Coverage Determination (LCD) L33370 referenced by the Plan does not provide coverage criteria for the requested services and was not used in the MAXIMUS determination.
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.