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

We decided that the Plan does not have to pre-approve Invermectin Cream 1% for enrollee.
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 excluded from coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Invermectin Cream 1% for
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) coded as E0652.
You asked the Plan to pre-approve the E0652 PCD. You say that the enrollee has tried a basic pump which was not helpful and made swelling worse. The Plan denied your request. The Plan says there is no full four-week trial of an E0651 pump documented.
The Plan follows Medicare rules. Medicare rules say that E0652 PCDs are covered when a four-week trial of an E0650/E0651 PCD has failed to improve symptoms. 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 E0652 PCD. Our reviewer says that the documentation does not support that the criteria for the requested PCD are met. Our physician reviewer found this enrollee has a history of uterine cancer and post-treatment abdominal and proximal swelling. The member has been treated with elevation, and compression (basic). Basic pump use is documented as having failed; causing genital swelling. The records however, do not indicate a 4-week reasonable trial of a standard pneumatic pump, has been approved and/or utilized. Since there is not sufficient evidence of the full four-week trial, the E0652 PCD is not considered 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 the E0652 PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) coded as E0652.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One knee injections.You asked the Plan to pre-approve the requested services. You say that you have responded well to the medication.The Plan denied your request. The Plan says you must try the preferred drug, which is just as effective.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 the requested services. Our physician reviewer found that you have a diagnosis of bilateral primary osteoarthritis of the knees. You had recent knee injections with steroid, which helped for 2 to 3 weeks. A Hyalgan knee series was recommended as the intra-articular steroid have not helped long-term. The Plan requires a trial of Monovisc before they will approve the requested drug. The documentation does not show that you have tried and failed the required drug. The documentation does not support that the plan's required drug would likely be less effective, or would likely have adverse effects.
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 Gel-One knee injections.
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 your therapy should be covered at the SNF level of care.The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of SNF care.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 does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. Our physician reviewer found that the enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. Our physician reviewer found that the enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Our physician reviewer found that the enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". Our physician reviewer found that, as a practical matter, the enrollee does not require the necessary services on 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.
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 clinical documentation provided supports the request for LTACH care.The Plan denied your request. The Plan says LTACH care 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 is currently undergoing treatment at an acute care hospital (ACH) following several recent falls resulting in rib fractures and compression fractures. Our physician reviewer found that the enrollee required a chest tube and spinal decompression surgery. Our physician reviewer found that the enrollee was intubated/ventilated and subsequently received a tracheotomy. Our physician reviewer found that, as of December 30, 2019, the enrollee was tolerating pressure support trials and was being transferred out of the ICU. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically reasonable and necessary.The Plan denied your request. The Plan says the clinical information received fails to support that the enrollee meets the requirements for coverage of an MRI.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee has many years of ongoing back pain. Our physician reviewer found that the enrollee underwent an epidural steroid injection with improvement in September 2019. Our physician reviewer found that the documentation does not outline new or concerning physical complaints, concerning findings on physical exam, recent imaging, new trauma, or other rationale for the requested test. Our physician reviewer found that the enrollee was noted to have improved symptoms with steroid injections.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent for the enrollee.
You asked the Plan to pre-approve Praluent. You say that based on the FDA indication, the treatment is medically necessary. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Praluent for the enrollee.
Benefits for Praluent 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 LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will have better care that is provided at an LTACH. The Plan denied your request. The Plan says the LTACH will not be providing services that are not available in the current 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 with ventilator management and oxygen supplementation, chest physical therapy, surveillance laboratory studies, tube feeding, 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 27, 2019.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee would benefit from continued care in the SNF. The Plan denied your request. The Plan says the enrollee no longer requires daily therapy in order to maintain his condition. Ongoing needs are custodial in nature.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 80 year old male with Lewy Body dementia and Parkinson's disease who was found to have a hip fracture on 12/6 for which he underwent hip hemiarthroplasty. He was then transferred to SNF on 12/7. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF. By the dates in question, the beneficiary was at a modified independent to supervision level with functional mobility including gait to 400 feet with a rolling walker. The beneficiary required varying assist with ADLs from supervision to minimal assist. He tolerated a regular diet and had moderate memory impairment. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration 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 the use of bone marrow aspirate is not covered for this procedure.

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 bone marrow aspirate remains experimental in cases of spinal fusion. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel 1.62% for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Androgel 1.62% 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show any of the covered indications.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation indicates you have a personal mobility deficit but it is unclear if this deficit impairs participation in MRADLs in the home. The documentation is not clear that you are unable to use a manual wheelchair. The records do not indicate an evaluation with a gait assessment and detailed upper and lower extremity musculoskeletal exam. There is no evaluation of your function with an appropriately fitted manual wheelchair or walker that may help her mobility deficit. There is no home evaluation indicating that you can safely operate a PMD in her home.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 wheelchair have not been met.Therefore, we decided that the Plan does not haveto pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nplate.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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chemotherapy-induced thrombocytopenia. The National Comprehensive Cancer Network (NCCN) guidelines do not address the use of Nplate in this circumstance. In addition, the enrollee is on oral etoposide and etoposide need not be held unless platelet counts are less than 50 and on last check this patient had a platelet count of 81. The service is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Nplate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTramadol tablets.You asked the Plan to pre-approveself-administered drugs. You say that enrollee has had disease progression and needs this drug.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered be Medicare part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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 MedicarePart B.Therefore, we decided that the Plan does not have to pre-approveTramadol tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe 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 shower chair.You asked the Plan to pre-approvea shower chair. You say that you have difficulty getting in the shower.The Plan denied your request. The Plan says this is not a covered item.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does
not require daily skilled therapy services.
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 SNF services. Our physician reviewer
found that the enrollee's chest x-ray was stable, and the urinalysis negative. He is at contact guard assist for
ambulation and transfers. He is at standby assist for bed mobility. This enrollee does not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and
effectively provide medically necessary and reasonable treatment. He does not have a tracheostomy tube,
enteral feedings, complex wound care or other SNF level skilled nursing need. He does not require skilled
therapy services of a qualified therapist required to safely and effectively provide medically necessary and
reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services
(or a combination of these services) on a daily basis. As a practical matter, he does not require the necessary
services on 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.