Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomographic Angiography (CTA) scan.
You asked the Plan to pre-approve CTA scan. You say that you are appealing based on your family history, and
your doctor recommends that you undergo this test. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because this CTA test is not medically necessary for you and is not
covered by Medicare for screening purposes.
The Plan follows Medicare rules. Medicare rules say that CTA scans are never covered for screening purposes.
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 CTA scan. Our reviewer says that you
do not meet the Medicare criteria for the requested CTA scan. Our physician reviewer found although you have
a family history of coronary artery disease (CAD) and some other risk factors, you are active and
asymptomatic. You have no chest discomfort, dyspnea, syncope, edema, or any other cardiac related signs or
symptoms. Medicare specifically does not cover screening assessment using CTA scan in an asymptomatic
individual. Therefore this test is not 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 CTA scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Computed Tomographic Angiography (CTA) scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp for the enrollee.You asked the Plan to pre-approveAranesp. The Plan denied your request. The Plan says that coverage guidelines have 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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. Documentation supports the enrollee has a hemoglobin level above 11 on the most recent tests. Guidelines state Aranesp is not indicated when hemoglobin exceeds 11g/dL. Our physician reviewer found that the enrollee's condition does not meet criteria for Aranesp.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oxygen concentrator for use with a continuous positive airway pressure (CPAP) device.You asked the Planto pre-approveoxygen concentrator. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the oxygen study was not a titration study and was not done with the CPAP, so this oxygen concentrator will not be covered at this time.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.
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 oxygen concentrator. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested oxygen concentrator. Our physician reviewer found an overnight oximetry test showed hypoxemia, but apparently the enrollee was not on CPAP for this test and there is no data from a CPAP titration study. It is therefore not known whether CPAP therapy alone, at settings that eliminate the sleep disordered breathing, will prevent hypoxemia. Therefore the medical necessity of home oxygen has not been demonstrated 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 oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvean oxygen concentrator for use with a continuous positive airway pressure (CPAP) device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Butrans for the enrollee.
You asked the Plan to pre-approve Butrans. You say that the enrollee needs to continue treatment. The Plan denied your request. The Plan says topical medications are not covered.
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 Butrans for the enrollee.
Benefits for Butrans may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator, any type, used with non-invasive interface.You asked the Plan to pre-approvea home ventilator (E0466). You say that non-invasive ventilation is critical for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator (E0466). Our physician reviewer found the enrollee has COPD and obstructive sleep apnea, as well as morbid obesity, and there may be anelement of obesity-hypoventilation syndrome. There is evidence for hypercarbic chronic respiratory failure. There is no evidence that BiPAP was tried in the home setting when the enrolleewas stable, so there is no documentation of BiPAP failure. Certain BiPAP hardware can provide the AVAPS-AE mode that is currently being provided by the ventilator. It is likely that BiPAP can meet the enrollee's respiratory support needs.  Medicare does not cover home ventilators when used as BiPAP devices.  A home ventilator is not medically necessary, and the denial is upheld.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator(E0466) have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator, any type, used with non-invasive interface.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 IRF admission is coveredonly when it is medically reasonable and necessary as described above.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 services are not medically necessary. Our physician reviewer found the submitted records show that you presented to the emergency department (ED) with slurred speech, facial droop, and left-sided weakness. He have improved with speech, occupational, and physical therapy in the hospital. You are walking 200 feet with supervision and need varied assistance with bed mobility, transfers, and dressing. You are medically stable with no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While you may benefit from further therapy, the records do not show that you require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services to be provided by out of network provider.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says that the requested services can be obtained from providers within the member's primary care physician's (PCP) referral circle.
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 pre-approved care. 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 the skilled nursing facility (SNF) services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cooling vest.
You asked the Plan to pre-approve the cooling vest. You say that you have an absence of sweat glands due to extensive burn scars which causes you to easily overheat and pass out. You feel that this shows that the cooling vest is medically necessary for you. The Plan denied your request. The Plan says this cannot be covered by Medicare.
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. Although it may be helpful for your medical condition, its primary purpose is not the treatment of a medical condition. As such, it does not meet the definition of durable medical equipment. Therefore, we decided that the Plan does not have to pre-approve a cooling vest.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa Injections (J7323).You asked the Plan to pre-approveEuflexxa. You say that the Euflexxa is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been 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 Euflexxa. Our reviewer says that the Euflexxa is not medically necessary. Our physician reviewer found there was no documented trial of the plan preferred drugs, Orthovisc and Monovisc. There is nothing in the record to suggest these drugs would be contraindicated or ineffective.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxahave not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa Injections (J7323).
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 needs intensive rehab in order to regain strength. The Plan denied your request. The Plan says the enrollee's medical condition is not complex enough to require frequent physician oversight of rehab or an intensive rehab program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 was admitted on 12/28/2019 due to shortness of breath, anemia, and Coumadin toxicity. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethigh and leg lipectomy with inpatient admission.You asked the Plan to pre-approvethese services. You say that you have excessive skin after weight loss.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have excessive skin in the thigh area but there is no documentation of a typical functional impairment related to the excessive skin. There is no documentation of failed conservative management. Based on the records and photographs, the procedures would be cosmetic in nature and not 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-approvethigh and leg lipectomy with inpatient admission.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET with CT scan for the enrollee.
You asked the Plan to pre-approve a PET with CT scan. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says that the requested services are not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET with CT scan. Our reviewer says
that the documentation does support that the requested PET with CT is medically reasonable and necessary.
Our physician reviewer found the enrollee was treated on protocol with neoadjuvant keytruda for melanoma.
The enrollee had axillary resection. Subsequent treatment strategy for melanoma is covered per Medicare rules.
Therefore, the enrollee meets criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET with CT scan have been met. Therefore, we decided that the Plan has to
pre-approve a PET with CT scan.
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 a pneumatic compression device (PCD) coded E0561
with full leg sleeve for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an E0651 PCD is 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 enrollee has lymphedema and
venous duplex testing revealed left lower limb acute occlusive thrombus. There is documented left leg
lymphedema and skin changes. There is no mention of hyperkeratosis or elephantiasis changes. The records do
not show that a standard pump trial of four weeks has been tried and failed. The requested PCD is not
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 a pneumatic compression device (PCD) coded E0561 with full leg sleeve for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit for "the beneficiary".You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 todetermine 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 anemia with chronic kidney disease. The enrollee has tried and failed the plan's required drug of Retacrit. The records do not show that Retacrit would be less effective or contraindicated for the enrollee; therefore, Procrit is not 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-approveProcrit for "the beneficiary".
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvetumor treatment field therapy (TTFT) for "the beneficiary".You asked the Plan to pre-approvethese 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. Medicare rules say that TTFT is 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 medically necessary. Our physician reviewer found the enrollee has a diagnosis of glioblastoma multiforme (GBM) on Optune and temador. The scans from October 2019 state that he is stable. Given that the scans are stable, continued Optune TTFT is 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-approvetumor treatment field therapy (TTFT) for "the beneficiary".If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked thePlan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include tracheostomy care with ventilator support, neurologic monitoring, intravenous steroids, telemetry as needed intravenous cardiovascular infusion, surveillance laboratory study, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.