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

We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway collapsibility for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there was no face-to-face evaluation before the sleep test.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a sleep study at home.
The study showed obstructive sleep apnea. Physician notes were submitted that were prior to the sleep study, but they do not document a need for the sleep study. Based on available records, the patient does not meet criteria for coverage of the requested oral appliance E0486. The records do not include a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea testing. There were records prior to testing, but they do not include an assessment for sleep apnea testing. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway collapsibility for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.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 is currently undergoing treatment at an ACH for sepsis and multi-organ failure. The enrollee has a tracheotomy at baseline and was placed on a ventilator during this hospitalization.  It is unclear if the enrollee is expected to be fully liberated from the ventilator.  The enrollee is not expected to be decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee is wheelchair-bound, severely disabled, and unable to perform daily activities, such as cooking and bathing. The Plan denied your request. The Plan says there is no evidence of being homebound.
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 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not have any complex skilled nursing needs and is not receiving home health skilled therapies. The records do not support the home health aide services reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Your needs are custodial in nature. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira pen injector for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has done well on this medication for several years. The Plan denied your request. The Plan says that this is not covered under the member's plan under any normal circumstances.
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 Humira pen injector for the enrollee.
Benefits for this drug 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: 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 without rehabilitation you will be sent to the hospital again, and you need this to regain full function of your body and live an independent lifestyle again.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 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 you are currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician 3 times per week or acute rehabilitation nursing care. While you may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidurography.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the documentation does not show why this is needed over a different type of image guidance that is more commonly used.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 requested services. Our physician reviewer found that you have spinal stenosis and degenerative disc disease. A lumbar epidural steroid injection is planned. Rationale for use of epidurography was not submitted with the request. The requested epidurography is not medically reasonable and necessary to treat your condition.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidurography.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genomic sequencing analysis for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says the test being requested is not limited to next generation sequencing but includes immune therapy and microsatellite instability
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 test. Our reviewer says that the requested test is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have metastatic prostate cancer. Testing related to prostate cancer and associated with specific therapies may be medically necessary and reasonable.
Testing unrelated to prostate cancer or not associated with specific therapy is not medically necessary or reasonable. The requested OmniSeq testing includes tests unrelated to prostate cancer and/or without associated treatments. The requested OmniSeq testing is not expected to change the enrollee's diagnosis, treatment or disease course. Therefore, the requested OmniSeq testing is not shown to bed medically necessary and reasonable. 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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve genomic sequencing analysis 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 this is medically necessary. The Plan denied your request. The Plan says SNF care can be approved if requested.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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-approve bilateral breast reduction mammoplasty.You asked the Plan to pre-approve the breast reduction procedure. You say that the requested surgery would be beneficial and should be approved.The Plan denied your request. The Plan says there has not been sufficient conservative management to warrant surgery at this time.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 breast reduction procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary. Our reviewer found The patient is a 37 year old female with evidence of bilateral breast hidradenitis in association with a right breast finding that requires lumpectomy by a Breast Surgeon. A request had been made for a left breast oncoplastic reduction and contralateral breast reduction to treat her bilateral hidradenitis and apocrine metaplasia. Based on the overall documentation provided for this case, there has been insufficient justification for the bilateral breast reduction. The examination detail from the Plastic Surgeon does notinclude adequate description of the breasts as it relates to the requested procedures. The degree of macromastia, degree of breast ptosis and degree of hidradenitis present has not been adequately documented. No photographs were provided to assist with this determination as well. A bilateral breast reduction may be justified, but there needs to be adequate documentation to support medical necessity. Overall, there is insufficient breast examination detail to adequately judge medical necessity. As reasoned above, there is insufficient documentation that a bilateral breast reduction(oncoplastic on one side and contralateral on the other side) would be medically necessary. From the documentation provided, it is not clear if the bilateral breast reduction would exceed the patient's needs. Greater breast examination detail, breast photographs and medical documentation from the Breast surgeon would be necessary to adequately determine medical necessity.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 breast reduction procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve bilateral breast reduction mammoplasty.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo and Yervoy injections for the enrollee.You asked the Plan to pre-approve the injections. You say that this is requested as first line therapy for malignant neoplasm of stomach, small cell carcinoma (HCC) and metastases to the liver.The Plan denied your request. The Plan says that this is not FDA approved for this condition.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 injections. Our reviewer says that the requested injections are medically reasonable and necessary. Our physician reviewer found this is a man with progression on primary therapy with small cell of the stomach with metastases to the liver. He has progressed within 6 months of primary therapy with carboplatin and etoposide. He now meets criteria for treatmenth with Opdivo/Yervoy according to the NCCN Guidelines Version 2.2020 Small Cell Lung Cancer. The treatment 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 the injections have been met.Therefore, we decided that the Plan has to pre-approve Opdivo and Yervoy injections for the enrollee.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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve combination chemotherapy with carboplatin and Abraxane (pemetrexed).You asked the Plan to pre-approve the carboplatin Abraxane combo therapy. You say that the enrollee requires this chemotherapy to treat his recurrent cancer.The Plandenied your request. The Plan says tha tthere is no literature to support the use of this regimen for the patient's condition.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 the carboplatin Abraxane combo therapy. Our reviewer says that the requested chemotherapy combination is considered medically reasonable and necessary in this case. Our physician reviewer found this patient with metastatic castrate-resistant prostate cancer now has progression and at least some element of small cell cancer. Per the NCCN Guidelines Version 4.2019 Prostate Cancer, the combination of carboplatin and docetaxel is a standard of care. As this patient already received docetaxel which was poorly tolerated and has some neuropathy, Abraxane is an acceptable substitute. The service 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 the carboplatin Abraxane combo therapy have been met.Therefore, we decided that the Plan has to pre-approvecombination chemotherapy with carboplatin and Abraxane (pemetrexed).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/orsend 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetrabeculoplasty by laser surgery (CPT 65855).You asked the Plan to pre-approvethe trabeculoplasty by laser surgery. You say that the records provided support the medical necessity of the services in dispute. You say that the enrollee's condition has worsened.The Plan denied your request. The Plan says the enrollee does not meet medical necessity for the procedure because her medication is keeping her eye pressure from getting worse.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 trabeculoplasty by laser surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the ophthalmology note dated September 13, 2019 documents that the enrollee's only ophthalmic medication is Artificial Tears. Our physician reviewer found that the intraocular pressure in the enrollee's left eye was 13 (normal). Our physician reviewer found that the note documents that "Glaucoma treatment with various combinations of eye drops will usually help to lower the eye pressure and prevent further damage. In advanced or poorly controlled cases, laser treatment or conventional glaucoma surgery may be necessary." Our physician reviewer found that the documentation does not support that the enrollee in this case has advanced or poorly controlled glaucoma.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 trabeculoplasty by laser surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvetrabeculoplasty by laser surgery (CPT 65855).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary, as there are complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says there is no medical necessity to move to the LTACH at this time.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include tracheostomy care with tracheotomy collar weaning trials, respiratory treatments, aspiration precautions, tube feedings, 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-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have the scan a PET/CT scan.You asked the Plan the scan the scan. You say that this is medically necessary.The Plan denied your request. The Plan says the requested study would exceed the allowed limit of three scans.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 the scan the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the requested scan would exceed the allowed number of scans per the NCD guidelines.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 scan have not been met.Therefore, we decided that the Plan does not have the scan a PET/CT scan.