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

We decided that the Plan does not have to pre-approve Monurol Pak Granules for the enrollee.
You asked the Plan to pre-approve Monurol. You say that the enrollee is allergic to other medications. The Plan denied your request. The Plan says Monurol Pak Granules to be taken at home is not covered under the Part B 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 Monurol Pak Granules for the enrollee.
Benefits for Monurol 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of IUD.
You asked the Plan to pre-approve the procedure. You say that this is needed due to excessive and frequent menstruation, and not for birth control. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that HCPCS J7298 is not a covered code. The codes being requested are for the hormone itself (HCPCS J7298) and the IUD (CPT 58300). As Medicare does not cover the hormone, the IUD that releases the hormone also cannot be covered. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of IUD.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xalatan solution.You asked the Plan to pre-approve Xalatan. You say that you had an allergic reaction to the generic brand.The Plan denied your request. The Plan says Xalatan to be administered at home is not covered under the Part B 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 Xalatan solution.Benefits for Xalatan may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are still undergoing physical therapy, and are recovering from sacral wounds. The Plan denied your request. The Plan says your plan pays for care in a SNF up to 100 days.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from August 9, 2019 to January 2, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature and M3 corpus to M5 corpus conversion.You asked the Plan to pre-approve these services. You say that you need these features to better adjust your position to help with transfers and need better safety features for shock absorption and steering correction.The Plan denied your request. The Plan says that these services are not covered. The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature and Group 4 power wheelchairs are not covered because they have added capabilities that are not needed in the home. We looked at the file and Medicare rules. The M3 corpus to M5 corpus conversion converts the power wheelchair into a Group 4 power wheelchair. 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 power seat elevation feature and M3 corpus to M5 corpus conversion.
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 enrollee is medically ready to transition to the LTACH where he will benefit from long term acute care hospitalization to retain maximum/prior level of functioning and a continued multi-disciplinary approach to care.The Plan denied your request. The Plan says the enrollee is receiving medically necessary acute and/or critical care. The plan says that the enrollee does not have clinical conditions that cannot be appropriately treated in the current 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 acute care hospital (ACH) after being struck by a car while riding a bicycle. Our physician reviewer found that the enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy and feeding tube. Our physician reviewer found that the enrollee appears to be neurologically intact and is tolerating pressure support on the ventilator. Our physician reviewer found that the enrollee's long-term goals and care plans are not elucidated. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required and can then be transferred/discharged to a lower level of care for any ongoing long term care 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Regeneten implant for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee continues to have hip pain and dysfunction. 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 enrollee presents with recalcitrant left hip pain and dysfunction. Clinical exam findings are generally consistent with intact surgical repairs, trochanteric bursitis and an iliotibial band tear. She has failed to improve despite reasonable conservative treatment, including activity modification, medications, and physical therapy. There are no large volume, long-term peer-reviewed outcome studies to support the use of a Regeneten implant for the enrollee's condition. Given the absence of medical evidence, this request for the use of the Regeneten implant for this enrollee's hip problem would not be considered the standard of care. Therefore, this request for Regeneten implant is not reasonable and medically necessary for treatment of this enrollee's medical 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Regeneten implant for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan has to pre-approve a pain pump for the enrollee.
You asked the Plan to pre-approve the requested pain pump. You say that the enrollee has had pain and limitations for over eight years. The Plan denied your request. The Plan says that the enrollee is responding well to oral medications.
The Plan follows Medicare rules. Medicare rules say that infusion pumps are only covered under certain medical indications. 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 pain pump. Our physician reviewer found that the enrollee has Complex Regional Pain Syndrome I. She had a Spinal Cord Stimulator placed, but apparently it did not receive much benefit from it. The enrollee is currently on Oxycontin, Duloxetine and Gabapentin. The enrollee also has psychiatric clearance. Oral opiates are not the evidence based approach to this disease. The requested pump will allow multi-modal drug therapy. Therefore, the requested procedure 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 the requested pain pump have been met. Therefore, we decided that the Plan has to pre-approve a pain pump 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: Unfavorable

We decided that the Plan does not have to pre-approve Amifostine injections (J0207) to be used during Stereotactic Body Radiation therapy (SBRT).
You asked the Plan to pre-approve the Amifostine injections. You say that Amifostine is an integral part of treatment of patients with prostate cancer using stereotactic body radiation therapy. The Plan denied your request. The Plan says the use of adjunctive medical therapy to prevent the development of radiation proctitis have had only a minimal effect, and such agents are not widely used.
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 this medication. Our reviewer says that the patient does not meet criteria for Amifostine injections. Our physician reviewer found that in the only study specific to SBRT, all patients received Amifostine, and therefore the benefit from the treatment cannot be discerned. Notably, the FDA approval for this drug does not seem to include an indication for this clinical scenario. There is limited data describing the use of intrarectal Amifostine for reducing rectal toxicity associated with prostate cancer radiotherapy. Additionally, there are no compelling reasons to believe that such treatment is to be effective in a clinically meaningful manner. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Amifostine injections (J0207) to be used during Stereotactic Body Radiation therapy (SBRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve the continuation of SNF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has reached her 100 day limit for this benefit period and has not gone 60 days in a row without being inpatient at any hospital or SNF.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 9, 2019 to December 31, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care for the enrollee.
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 requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for sepsis due to pressure wounds in the setting of cerebral palsy. The enrollee required intubation/ventilation and subsequently received a tracheotomy. The enrollee remains on a ventilator and is described as being unable to manage his own oral secretions and in need of long term care placement. It does not appear that ventilator liberation or decannulation are expected. 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 long term care 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be provided at a lower level of care, such as a skilled nursing facility.
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 three times per week or acute rehab nursing care. While you may benefit from continuing ST, PT and OT, 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve additional mileage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you are asking for a total of 203 miles per one-way trip to your destination. The Plan says that your contract clearly states you are only covered for up to 50 miles per one-way trip.
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 a maximum of 12 one-way transportation trips per year, not to exceed 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The file shows you are asking for a total of 203 miles per one-way trip to your destination. Your contract clearly states you are only covered for up to 50 miles per one-way trip. Therefore, we decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no medical evidence per review of peer reviewed medical literature and established treatment guidelines that the use of Keytruda for Stage II vaginal cancer adenocarcinoma is supported/effective/medically reasonable established treatment.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services.. You say that the enrollee needs time at the SNF in order to get stronger. The Plan denied your request. The Plan says SNF care is not supported based on the records provided. The plan says that the enrollee's needs can be met at home or at an assisted living facility with help from a caregiver and part-time therapies.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and tolerated dialysis three times per week. Our physician reviewer found that the enrollee received physical and occupational therapy in the acute hospital. Our physician reviewer found that the enrollee was at a stand by assist to contact guard/minimal assist level with function mobility, including gait to 200 feet with a rolling walker. Our physician reviewer found that the enrollee required varying assist with activities of daily living. Our physician reviewer found that there are no identifiable skilled nursing service needs. Our physician reviewer found that, while there are identifiable skilled therapy service needs, they are not required on a daily basis. Our physician reviewer found that the enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.