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

We decided that the Plan does not have to pre-approve Retacrit.You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Retacrit.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 Retacrit. Our reviewer says that the enrollee does not meet criteria for the requested Retacrit. Our physician reviewer found this review relates to a request for Retacrit, an erythropoietin stimulating agent (ESA) to treat a man with newly diagnosed myelodysplastic syndrome (MDS). The documentation does not indicate the enrollee has had any transfusions. Therefore, there is no indication the use of the drug will end or reduce the need for transfusions.The documentation states the enrollee does not have any complaints. No symptoms are noted in the submitted office note. Therefore the requested use of Retacrit does not meet the requirements of LCD L34633.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Retacrit.
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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee required moderate assistance with bed mobility and walking 10 feet
times two. The enrollee required minimum assistance with transfers, bed mobility, and lower body dressing.
The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not
require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple
therapies such as physical therapy and occupational therapy, however, the documentation does not support that
the enrollee's functional status with decreased endurance requires intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. You say that you were not aware this provider and facility were no longer in-network. You say you do not want to go to a different provider as you are very satisfied with this provider's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out-of-network medical services. You say that it is urgent for the enrollee to have a bloodless stem cell transplant done. You say that, upon doing research 6 months ago, you have been in contact with the Plan's in-network provider and they gave you the name of the out-of-network provider. You say that your mother is losing stem cell counts every time she goes in for her weekly chemotherapy.The Plan denied your request. The Plan says they have verified with the in-network provider that they are able to supply a bloodless stem cell transplant service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve to a SNF. You say that the request for admission to a SNF is medically necessary. The Plan denied your request. The Plan says the request for admission to a SNF does not meet criteria.
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 to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no skilled nursing needs. The member is not receiving IV medications or fluids. Routine monitoring of her chronic medical conditions is being done such as assessment of pain, routine administration of oral medications, support of chronic physical debilities, and assessment of her skin. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. The member has not returned to her prior level of function. The member requires physical therapy for progression of her mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The member is receiving care that can be provided by non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda injections.
You asked the Plan to pre-approve Keytruda injections. You say that Keytruda injections are medically necessary. The Plan denied your request. The Plan says Keytruda injections are not medically necessary.
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 injections. Our reviewer says that Keytruda injections are not medically necessary. Our physician reviewer found the enrollee is with metastatic castration resistant prostate cancer with Guardant360 testing found not detected for microsatellite instability (MSI) high. The drug is not FDA approved for prostate cancer unless it is MSI high or mismatch repair deficient. The use of the drug is not supported in any of the CMS approved compendia for prostate cancer without MSI-high. This reviewer did not find any supporting citations in a PubMed search. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from November 8, 2019 to November 14, 2019.You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel the enrollee should not be responsible for this cost sharing amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says the enrollee was admitted as inpatient on the dates of service at issue in this appeal. The Plan states the correct copayment has applied per the enrollee's contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment each day for days 1 to 4 for Medicare-covered hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows the enrollee was admitted as inpatient from November 8, 2019 to November 14, 2019. The enrollee has been asked to pay a $350 copayment for days 1 to 4, totaling $1580. The inpatient hospital services fall within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from November 8, 2019 to November 14, 2019.MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 enrollee does not meet the criteria for coverage. Our physician reviewer found a note from February 14, 2020 states that the enrollee should have a 30 degree angle of the head to the bed. However, the documentation does not support that her condition requires frequent changes in body position, immediate changes in body position, or positioning of the body in ways not feasible in an ordinary bed. She does not require special attachments that cannot be fixed and used on an ordinary bed. The requested semi-electric hospital bed 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 a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed (E0260). You say that the requested semi-electric hospital bed is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested semi-electric hospital bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed (E0260). Our reviewer says that the enrollee does not meet Medicare criteria for the requested semi-electric hospital bed. Our physician reviewer found the enrollee was recently admitted 2/24/2020 - 3/4/2020 with malaise, weakness, and dehydration status post medical management. The member has ongoing combative behavior at home. The report dated 4/6/2020 indicates this enrollee is now cheerful, but confused. There is no documented ambulatory inability or pressure ulceration. Diagnoses listed is Alzheimer's disease, chronic obstructive pulmonary disease (COPD), hypertension (HTN), and arthritis. A hospital bed is not medically necessary, as there is no documented mention the enrollee requires immediate/frequent changes in body position or special attachments that cannot be fixed to an ordinary bed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0260) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 11, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve the Keytruda. You say that the enrollee had disease progression and underwent another resection. He received adjuvant radiation, followed by third-line lomustine therapy. However, the most recent MRI from April 2020 has once again showed progressive disease of the enrollee's glioblastoma. He requires further systemic treatment and has exhausted all FDA-approved therapies. You say that it is your professional opinion that Pembrolizumab is the next best treatment option for the enrollee. You say that additional clinical trials have investigated another anti-PD-1 immunotherapy, nivolumab, for treatment of glioblastoma and have demonstrated some durable responses. The Plan denied your request. The Plan says the requested drug is not supported by Medicare recognized compendia, nor in the peer reviewed journals.
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 Keytruda. Our reviewer says that there is no compendia basis or literature support for the requested drug. Our physician reviewer found the documentation does not support the Keytruda is medically reasonable and necessary for the enrollee. The documentation does not support that Keytruda is safe and effective for the enrollee. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy (J9228) and Nivolumab (J9299).

You asked the Plan to pre-approve Yervoy and Nivolumab. You say that the requested medications are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Yervoy and Nivolumab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of small cell lung cancer with metastatic brain lesions. The enrollee has been treated with both chemotherapy and immunotherapy. Review of compendia and literature, the requested treatment regimen is for individuals without disease progression on immunotherapy regimens. This is not supported by reviewed records. 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 Yervoy and Nivolumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy (J9228) and Nivolumab (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic to be provided by an out of network provider.
You asked the Plan to pre-approve the lower extremity prosthetic from an out-of-network provider. You say that the enrollee wants to continue to use your office. The Plan denied your request. The Plan says the prosthetic is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the prosthetic to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair for the enrollee.
You asked the Plan to pre-approve a seat lift chair. The Plan denied your request. The Plan says that the enrollee does not have the medical condition that is needed to be approved for a power seat lift chair.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. The file indicates the enrollee is independent with transfers. Based on this information, we decided that Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair for the enrollee.