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

We decided that the Plan does not have to pre-approve the Otezla 30mg tablets.
You asked the Plan to pre-approve the Otezla tablets. You say that this is needed to treat plaque psoriasis. The Plan denied your request. The Plan says this oral drug is not covered by Medicare 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 the Otezla 30mg tablets.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Mild procedure (0275T).
You asked the Plan to pre-approve the Mild procedure (0275T). You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.
We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar decompression or commercially known as the mild procedure will be covered when provided in an approved clinical study. The file does not show that the enrollee is enrolled in an approved clinical study. Therefore, we decided that the Plan does not have to pre-approve the Mild procedure (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary.The Plan denied your request. The Plan says the LTACH admission is notmedically 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 that the enrolleeis currently undergoing treatment at an acute care hospital (ACH) for sepsis.The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee does not appear to have tolerated any weaning to date. Her long-term prognosis is unclear. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee tothe 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, thefile, 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of Prolia.You asked the Plan to pre-approveProlia. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan requires a trial of Zoledronic Acid before it will approve Prolia.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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The documentation submitted does not support that Zoledronic Acid would likely be less effective and/or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from June 30, 2019 to July 8, 2019.You asked the Plan to pay forthe skilled nursing services. You say that your foot surgeon stated that you were non-weight bearing with dressing changes daily on both legs and feet.The Plan denied your request. The Plan says custodial/supportive care is not covered in your benefit document and therefore is not eligible for coverage.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 pay for the skilled nursing services. Our reviewer says that you did not meet the Medicare criteria for SNF care. Our physician reviewer foundthatyou did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy onan inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 30, 2019 to July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON oral surgery services. You say that the enrollee has aggressive cancer and needs to be surgically treated as soon as possible. The Plan denied your request. The Plan says they are a network provider who is able to see this patient within a short time. As there is a network provider, there is no need for OON referral.
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 oral surgery services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve pulmonary rehabilitation services for the enrollee. You asked the Plan to pre-approve the rehab services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of nutritional counseling, lung volume reduction surgery, or evaluation or treatment for sleep disorders. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 rehab services. Our reviewer says that the requested rehab services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has mild restrictive lung disease on PFTs, but moderately advanced pulmonary fibrosis with pulmonary hypertension. The enrollee is very symptomatic. The medical record does not indicate any issues with nutrition or sleep-related symptoms. Lung volume reduction surgery is not appropriate for restrictive lung disease and is not a pre-requisite for pulmonary rehabilitation. PR is indicated for "...mild to severe chronic lung disease...", and this enrollee meets that criterion. She would most likely benefit from PR, with improvement in exertional dyspnea and quality of life 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 rehab services have been met. Therefore, we decided that the Plan has to pre-approve pulmonary rehabilitation services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve use of the tumor treatment field therapy (TTFT) device.
You asked the Plan to pre-approve the TTFT device. You say that this should be approved. The Plan denied your request. The Plan says that the documentation does not show that RANO criteria or Karnofsky score criterion are met.
The Plan follows Medicare rules. Medicare rules say that TTFT is covered when the above listed criteria are met. 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 TTFT device. Our reviewer says that the requested treatment is considered reasonable and necessary based on LCD criteria. Our physician reviewer found this is newly diagnosed grade IV astrocytoma which has been treated with debulking surgery followed by chemoradiation. The December 2019 MRI shows that there has been no progression and the records show that the patient's performance score is at least 70. This is a medically necessary treatment. 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 TTFT device have been met. Therefore, we decided that the Plan has to pre-approve use of the tumor treatment field therapy (TTFT) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond February 23, 2020.
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you have exhausted the benefit limit.
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 November 19, 2019 to February 23, 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 approve continued skilled nursing facility (SNF) services beyond February 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips (A4253).
You asked the Plan to pre-approve One Touch Ultra test strips. You say that the requested items 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. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of test strips have not been met. Specifically, medical records were not provided. Without this documentation medical necessity for the specific brand requested is not able to be established. Therefore, we decided that the Plan does not have to pre-approve test strips (A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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 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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve panel genetic testing for inherited breast and ovarian cancer syndromes (81432).
You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the member already had BRCA testing in 2012 and it was negative.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 genetic testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found panel testing is now considered a standard of care in patients at high risk to carry a genetic mutation such as this one. 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 genetic testing have been met. Therefore, we decided that the Plan has to pre-approve panel genetic testing for inherited breast and ovarian cancer syndromes (81432).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre test strips.
You asked the Plan to pre-approve FreeStyle Libre test strips. You say that this should be reconsidered because you will benefit from this device. The Plan denied your request. The Plan says the criteria for coverage of CGM supplies have not been met.
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered if the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. We looked at the file and Medicare rules. The record does not show that you are insulin treated with three or more daily injections or a CSII pump. Based on this information, we decided that Medicare rules for coverage of FreeStyle Libre test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ZILRETTA.
You asked the Plan to pre-approve ZILRETTA. The Plan denied your request. The Plan says that it is unknown if you have tried and failed to have an adequate response to injectable triamcinolone.
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 ZILRETTA. Our reviewer says that ZILRETTA is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed injectable triamcinolone or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that your condition does not meet step therapy criteria for ZILRETTA. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ZILRETTA have not been met. Therefore, we decided that the Plan does not have to pre-approve ZILRETTA.
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 admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee came to the emergency room with complaint of having some right upper quadrant pain. The enrollee was managed for abdominal abscess, and co-morbid prior hepatic cancer status post chemotherapy, as well as type 2 diabetes mellitus. The recent records indicate the enrollee has ongoing wound care needs, and limitations with regards to mobility and activities of daily living. The enrollee needs minimal/moderate assistance as of 3/12/2020 for activities of daily living, and mobility. Pain limits mobility and interferes with therapy participation. The enrollee is now mostly minimal/moderate assist for care. The enrollee has no complex nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable and SNF is not 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 admission to a skilled nursing facility (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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH 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 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 services are not medically necessary. Our physician reviewer found the enrollee's ongoing care needs include respiratory support with ventilator management, hemodialysis, 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 she 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.