Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve admission to a long term acute care hospital (LTACH).You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting, such as home, a long term care facility, or other outpatient 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation, surveillance laboratory studies, nutritional support, occupational and physical 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 Plandoes not have to pre-approve admission to a long term acute care hospital (LTACH).
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 requires daily physician visits, nursing care, and intensive therapies. The Plan denied your request. The Plan says the enrollee has no other significant needs other than weaning him off of oxygen.
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 oxygen supplementation with intermittent BiPAP support, respiratory treatments, surveillance laboratory studies, 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: 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 medically deserves a transfer to an LTACH in order to continue with ventilator weaning and physical therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for coverage. The plan says that the services needed by the enrollee could be provided in another 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 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 ventilator and tracheostomy care, surveillance laboratory studies, cervical collar and spine precautions, peg tube feedings, turn and positioning, 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that additional rehabilitation therapy would be beneficial for the enrollee.The Plan denied your request. The Plan says that based on the documentation provided, medical necessity for daily skilled services has not been established. Therefore, coverage criteria have not been met.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 care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is in need of strengthening, transfer training and occupational therapy. A period of daily skilled services is required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point cannot be provided at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFentanyl 25mcg/hr patch.You asked the Plan to pre-approveFentanyl 25mcg/hr patch.You say that the requested medication is necessary.The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveFentanyl 25mcg/hr patch.Benefits for Fentanyl 25mcg/hr patchmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve the Euflexxa. You say that the enrollee received the Supartz in the past and it helped with knee pain. You say that the clinic doesn't use Orthovisc or Monovisc due to the high cost and low reimbursement of the medicine. The Plan denied your request. The Plan says the enrollee does not meet the step therapy requirements.

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 Euflexxa. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the injection in dispute is being requested for treatment of osteoarthritis in bilateral knees. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments, such as Orthovisc and Monovisc. Our physician reviewer found that the documentation provided does not outline contraindications or reasons why these medications were not considered.

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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
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 the plan has also denied LTACH services and wants
to discharge her unsafely. The appellant say that she was recommended to IRF by physical and occupational
therapy. The Plan denied your request. The Plan says admission to an IRF is not reasonable or medically
necessary. The Plan says that there is not documentation showing that the enrollee requires an intensive and
coordinated interdisciplinary approach in an inpatient rehabilitation therapy program, with frequent physician
supervision by a rehabilitation physician.
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 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. Our physician
reviewer found that the records provided show that the enrollee cannot tolerate acute IRF level of therapies.
Our physician reviewer found that the enrollee is medically stable and that, while she may benefit from further
physical therapy, she does not require an intensive therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a leadless pacemaker.You asked the Plan to pre-approve the leadless pacemaker. You say that you feel that this should be approved.The Plan denied your request. The Plan says Medicare only covers this type of pacemaker under CED. Since this patient is not enrolled in an approved study, the leadless pacemaker is not covered.The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered under CED. They are covered for those participating in approved studies. In this case, there is no evidence that the enrollee is participating or planning to participate in a study in relation to the leadless pacemaker.Therefore, we decided that the Plandoes not have to pre-approve placement of a leadless pacemaker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for "the beneficiary". You asked the Plan to pre-approveIRF care. You say that the enrollee needs rehab.The Plan denied your request. The Plan says the services are 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 requestto pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 19, 2019 for obstructive hydrocephalus after shunt placement. She had a shunt placed on November 21, 2019 and was transferred to a long-term acute care hospital (LTACH) on December 14, 2019. Her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. She may benefit from multiple therapies, but the records do not show that she would be able to tolerate and benefit from an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the "beneficiary".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carboplatin/Alimta chemotherapy with Opdivo (nivolumab).
You asked the Plan to pre-approve the chemotherapy with Opdivo. You say that the enrollee needs to start his chemotherapy for his stage IV cancer. The Plan denied your request. The Plan says the requested chemotherapy regimen is not approved for this condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the chemotherapy with Opdivo. Our reviewer says that the requested use of Opdivo for first line therapy is not medically reasonable and necessary. Our physician reviewer found this patient with metastatic non-small cell lung cancer has not received primary therapy for his cancer. PD-L1 and driver mutations were attempted but there was insufficient tissue. Nivolumab (Opdivo) is only approved for the treatment of metastatic non-small cell lung cancer (NSCLC) that has progressed on or after platinum-based chemotherapy. The combination proposed is not a standard 1st line therapy. There is not sufficient evidence in the compendia to support this use. 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 chemotherapy with Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin/Alimta chemotherapy with Opdivo (nivolumab).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.You asked the Plan to pre-approve Rituxan. You say that the patient has Non-Hodgkin Lymphoma and need to get it under control and get it every 8 weeks.The Plan denied your request. The Plan says that in order to be covered under Part B the medication must be supplied by the provider.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.Benefits for Rituxan 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: 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. The Plan denied your request. The Plan says that you do not appear to have any skilled nursing needs at this time.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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.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 continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiation services to be provided by an out-of-referral circle provider.You asked the Plan to pre-approvethe requested services. You say that you are not able to get to your appointments because it's too far.The Plan denied your request. The Plan says the requested services are available within your referral circle.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 pre-approvedcare.The requested provider in this case is not a part of your referral circle. The Plan has network providers available in your referral circle who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approveradiation services to be provided by an out-of-referral circle provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3 (J7328).You asked the Plan to pre-approveGelsyn-3. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, criteria for a step therapy exception has not been met.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 Gelsyn-3. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the plan's required drugs would likely be less effective, and/or would likely have adverse effects for you in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met.Therefore, we decided that the Plan does not have to pre-approveGelsyn-3 (J7328).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the Vertiflex device has not been proven to improve the symptoms and management of your spinal stenosis.
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 interspinous spacer devices remain experimental. Complications have been reported with the use of such devices. It is not yet clear how interspinous spacers compare with other forms of treatment in terms of effectiveness, adverse effects, and long-term outcomes. Additional research is necessary to demonstrate the safety and efficacy of interspinous spacer devices. 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 a Vertiflex interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories for the enrollee.You asked the Plan to pre-approve the denied options. The Plan denied your request. The Plan says replacement codes are not used at the time of initial issue.The Plan must follow Medicare rules. Medicare rules say that in order for a beneficiary's equipment to be eligible for reimbursement,the reasonable and necessary requirements set out must be met.The file shows that a replacement only joystick (E2374), and an arm pad replacement (K0019) was requested. We looked at the file and Medicare rules. These codes are for replacement items and not used at the time of initial issue. An Led Light Package R-Netkit through the joystick (K0108) was also requested. The records show that this is already included in the expandable control approved by the plan. 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 power wheelchair accessories for the enrollee.