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

We decided that the Plan does not have to pre-approve Triluron.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is a step therapy requirement.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation of a trial and failure of the required drugs. There is no indication that the required drugs would likely be less effective and/or 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Triluron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress for the enrollee.

You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the mattress. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this 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 the mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fulphila.

You asked the Plan to pre-approve Fulphila. The Plan denied your request. The Plan says routine costs
associated with a clinical trial are the responsibility of Original Medicare.

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.

In this case, you asked the Plan to pre-approve Fulphila as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to
pre-approve Fulphila.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the enrollee never met with provider either in person or through telehealth services.

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 knee orthosis and suspension sleeve. Our reviewer says that the service was not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio 300mg vial (every six weeks).

You asked the Plan to pre-approve the dosage. You say that this is medically necessary. The Plan denied your request. The Plan says

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 the dosage. Our reviewer says that the requested dosage is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved drug compendia there is no documentation that Entyvio 300 mg every 6 weeks is medically reasonable, necessary, safe or effective 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 the dosage have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio 300mg vial (every six weeks).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and knee feature.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a request for a new prosthesis with K3 components does not meet Medicare criteria as
reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not include objective physician or treating medical provider physical
exam/medical progress notes that support that you are a K3 ambulator.

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 a prosthetic leg with an advanced foot and knee feature.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the inpatient hospital admission.

You asked the Plan to pre-approve the inpatient admission. You say that it is felt that the enrollee required inpatient admission for her condition. The Plan denied your request. The Plan says that the enrollee could have been sent home as she has a 24-hour caregiver. There was no need for inpatient hospital care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient admission. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee is a 96 year old female who was presented to the emergency room with neck pain after a fall. Computed tomography (CT) imaging of the neck showed a thoracic compression fracture of unknown age. The review indicates that the record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 inpatient admission have been met. Therefore, we decided that the Plan has to pre-approve the inpatient hospital admission.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 gene analysis and F5 gene analysis.

You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for
the requested services.

The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F2 and F5 genes for all
risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are noncovered
except for pregnant patients.

The plan uses Local Coverage Determination (LCD) L36155 to support their denial. However, LCD L36155 is
not valid for the enrollee's home state of Washington. Therefore, we cannot use LCD L36155 to substantiate
our decision.

We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant.
Based on this information, we decided that Medicare rules for coverage of F2 gene analysis and F5 gene
analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 gene analysis
and F5 gene analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve a continuous glucose monitor. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a continuous
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation of the SI joint 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 Medicare considers this procedure as experimental and investigational.

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 this is considered an experimental/investigational procedure because of the wide variation in efficacy
reported in the literature. Therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bilateral radiofrequency ablation of the SI joint for the enrollee.
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 enrollee would benefit from intensive therapy. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.

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 patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require or appear to tolerate this therapy on an 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brow repair surgery (67900).

You asked the Plan to pre-approve the brow repair surgery. You say that the surgical procedure is medically
necessary. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the brow repair surgery. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the photographs provided did not support the need for brow ptosis repair.

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 brow repair surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve a brow repair surgery (67900).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 02/07/2021. She was diagnosed with a lung infection (pneumonia) due to COVID 19. She was treated with medication and required supplemental oxygen. She has also been treated for congestive heart failure. 

There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at high risk for readmission if she is not properly managed. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute 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 the enrollee was admitted to the current acute care hospital with shortness of breath related to CHF. She was treated with high flow oxygen, antibiotics, steroids, Foley catheter, and diuresis. Recent notes state that the enrollee is less short of breath, and gradually weaning down on oxygen. The enrollee appears to be improving and only requires short term additional acute care services, which can be safely completed at the current facility. She does not require services at the LTACH that are not already being provided at the current facility. Therefore, this request for LTACH services is not supported and will be considered 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was hospitalized following a motor vehicle crash. He also had respiratory failure from the Covid-19 virus. The record sent by your provider indicates treatment has greatly improved his condition and he is being weaned off his high-flow oxygen. Currently, he requires oxygen at 14 liters per minute by nasal cannula. 

There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met 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 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.