Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS device for "the beneficiary". You asked the Plan to pre-approvethe requested services. You say that the device will help manage the enrollee's medications and fluid status prior to developing symptoms.The Plan denied your request. The Plan says the requested device is considered investigational.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 the enrollee has a history of hypertension, dyslipidemia, sleep apnea and diastolic heart failure requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Concerns have been raised about potential bias in this trial, calling into question the results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met as the device shouldstill be considered experimental or investigational.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-approvea CardioMEMS device for "the beneficiary".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place of an acute care 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 ongoing care needs include oxygen vapotherm supplementation with nighttime BiPAP, surveillance laboratory studies, oral immunosuppressant agents, and therapy services. Our physician reviewer found that 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued progress toward their baseline. The Plan denied your request. The Plan says ongoing acute care needs can be met at the current acute care setting.
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 physician reviewer found 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 intravenous antibiotics, surveillance laboratory studies, colostomy and wound care, transfusion as indicated, 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the requested injection. The Plan denied your request. The Plan says there is no indication that the enrollee has had advanced imaging or conservative management.
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 injection. Our physician reviewer found that the enrollee had the sudden onset of pain a few weeks ago with pain going down both arms and complaints included paresthesia. He was having paresthesia down both arms with tingling in his fingers bilaterally. He had noticed some weakness. He was not currently taking any medications. He had pain ranging from 8-9 out of 10. Physical examination findings included cervical neck pain with palpation. There was decreased range of motion. He had normal strength. There were postoperative findings and degenerative disc disease was noted at C6/7. There was no instability on flexion/extension views. There is no evidence of a failure of conservative treatments including the prednisone that was prescribed. There are no findings of radiculopathy by physical examination, such as decreased strength in a myotomal pattern, decreased dermatomal distribution sensation, or asymmetric reflex response. There is also no recent MRI scan that corroborates findings of radiculopathy. Lastly, symptoms have only been present for a few weeks, which does not reflect a failure of conservative treatments. For these reasons the requested cervical epidural injection is not considered 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 the requested injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has shown vast improvements in his overall health. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, 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, ventilator support with respiratory suctioning and nebulizer treatments, surveillance laboratory studies, tube feedings, hemodialysis, wound care, and neurologic monitoring. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation system for the enrollee's power wheelchair.
You asked the Plan to pre-approve the seat elevation system. The Plan denied your request. The Plan says a seat lift does not serve a medical purpose.
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are covered when the reasonable and necessary requirements are met.
We looked at the file and Medicare rules. A power seat elevation feature is non-covered because it is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevation system for the enrollee's power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you need the sensor for your Medtronic 670G pump to work. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. The rules say that a sensor described by code A9276 is for a non-therapeutic CGM. The requested service is a sensor for a CGM described by code A9276. This sensor is used for a non-therapeutic CGM, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a sensor for a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical anterior decompression with fusion (single level) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the notes provided by the doctor do not show a lack of use of nicotine products for at least six weeks.
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 surgery. Our reviewer says that the requested surgery is not medically reasonable or necessary. Our physician reviewer found cervical artificial disc replacement is experimental when combined with fusion surgery. It is not FDA approved for both. The surgery is experimental. More research is needed. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical anterior decompression with fusion (single level) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveKeytruda (J9271).You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe use of this drug requires the tumor has PD-L1 expression = 1%.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of adenocarcinoma of the right lung with positive lymph nodes. Submitted documentation documentsthat you have Tumor Proportion Score 0% for PD-L1 expression. Documentation supports the use of Keytruda for this cancer when there is PD-L1 gene expression. Medical necessity is not determined.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveKeytruda (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto 24mg-26mg tablet.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is a medical only policy with the plan.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 haveto pre-approve Entresto 24mg-26mg tablet.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Logisticare mileage You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary.The Plan denied your request. The Plan says the service is a covered benefit, but the enrollee has exceeded the limit set in the subscriber agreement.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine trips up to 50 miles one-way.The requested trip is 8 miles over the limit.Based on this information, we decided that the Plan's rules for coverage of the additional mileage have not been met.Therefore, we decided that the Plan does not have to pre-approve additional Logisticare mileage
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth #3.
You asked the Plan to pre-approve the dental crown for tooth #3. You say that the doctor did not finish the work he billed for. You say that the doctor only provided you with a temporary crown and that, upon follow-up for continued pain, this dentist advised you that you would need a root canal. You say that you do not trust this dentist. You say that you have found another dentist to complete the work and request that the plan authorize the crown requested for tooth #3. The Plan denied your request. The Plan says the requested service exceeds the maximum count allowed per period.
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 coverage for crowns is limited to one procedure every three years. The records show that the plan paid for a crown procedure for tooth #3 provided by the doctor. Therefore, we decided that the Plan does not have to pre-approve a dental crown for tooth #3. Our decision is in regards to coverage of the requested crown. Your complaint regarding the care you received from the doctor is considered a grievance and must be addressed by the Plan separately. Medicare does not permit us to make decisions about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says LTACH admission is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute
care hospital where they are currently receiving care. All medically necessary care is being provided in the
current long term care setting. There are no services available at the LTACH that the enrollee requires that are
not available at the health care setting being offered by the health plan. The enrollee has no acute 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approvet he IRF admission. You say that the enrollee would benefit from more intensive rehab due to her Parkinson's disease.The Plan denied your request. The Plan says that there is no evidence that hospital level care is needed. Approval has been granted for rehab in the skilled nursing facility setting.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.In this case, the Plan did not forward any medical records related to this request. MAXIMUS is not able to determine whether IRF care is necessary without reviewing the records of the hospital admission. We find that the Plan has not substantiated the denial.Therefore, we decided that the Planhas to pre-approve admission to an inpatient rehabilitation facility (IRF).If the Plandoes 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 toreview. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the self-administered drugs provided by
the Hospital on June 4, 2019.
You asked the Plan to issue reimbursement for these self-administered drugs. You say that you are requesting
reconsideration of the plan's denial. The Plan denied your request. The Plan says that self-administered drugs
are not a covered benefit under your policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs provided are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to issue reimbursement for the selfadministered
drugs provided by the Hospital on June 4, 2019.
Benefits for these self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Sodium 1% Gel.You asked the Plan to pre-approve Diclofenac Sodium. You say that the Diclofenac Sodium is medically necessary.The Plan denied your request. The Plan says coverage for Diclofenac Sodium is not available under the Part B Medical Benefit.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 Diclofenac Sodium 1% Gel.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz FX (J7321).You asked the Plan to pre-approveSupartz. You say that Supartz is medically necessary.The Plan denied your request. The Plan says the enrollee must trial the plan preferred agents, Orthovisc and Monovisc before alternatives will be considered.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 Supartz. Our reviewer says that the Supartz is not medically necessary. Our physician reviewer found the record does not show that the plan alternatives Orthovisc and Monovisc have been trialed or would be unsafe or ineffective 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 Supartz have not been met.Therefore, we decidedthat the Plan does not have to pre-approveSupartz FX (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement standard wheelchair.
You asked the Plan to pre-approve a replacement standard wheelchair. You say that your wheelchair is messed up and you need a wider wheel. The Plan denied your request. The Plan says you have a standard wheelchair that is only a year old and still under reasonable useful lifetime.
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 you have a standard wheelchair. The standard wheelchair serves the same purpose as a replacement standard wheelchair. The supplier has stated that the manual wheelchair was misused and damaged. Therefore, we decided that the Plan does not have to pre-approve a replacement standard wheelchair.