Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF admission.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 enrollee meets criteria for admission to a SNF. Our physician reviewer found the enrollee does require skilled nursing services, i.e., are the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., are the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. It is medically reasonable and necessary to provide these skilled nursing services (notably wound care for a stage 3 pressure ulcer) on a daily basis. The enrollee requires daily skilled nursing for adequate wound care.As a practical matter, this enrollee does require the necessary services on an inpatient basis, in a skilled nursing facilitysetting.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-approveskilled nursing facility (SNF) care.
If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNeulasta Onpro.You asked the Plan to pre-approveNeulasta Onpro. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Neulasta Onpro. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has a high risk of febrile neutropenia. This drug is indicated with a risk of febrile neutropenia (FN) of greater than 20% based on current chemotherapy regimen (as listed in current ASCO and NCCN guidelines for myeloid growth factors) OR risk of febrile neutropenia (FN) of 10-20% based on current chemotherapy and one or more risk factors. In this case, the enrollee has been receiving Lurbinectedin for extensive stage small cell lung cancer. Lurbinectedin carries a low risk for FN, per MM (7%). Also, while on Lurbinectedin, the enrollee has an ANC of 3.5 (February 11, 2021), thus would not be considered to be neutropenia. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta Onpro have not been met.Therefore, we decided that the Plan does not have to pre-approveNeulasta Onpro.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for radiation therapy.

You asked the Plan to pre-approve the referral. You say that intra-operative radiation will decrease the enrollee's risk of COVID-19 exposure.The Plan denied your request. The Plan says the plan requires use of participating providers.

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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it does not seem necessary for her to receive this treatment out of network unless the same or comparable treatment (including standard of care external beam radiation) could not be offered in network. While the letter of appeal mentions that the same treatment is not offered in network, there is no documentation that a comparable equally efficacious treatment is not offered in network (and no plausible reason to think that to be the 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 the referral have not been met.Therefore, we decided that the Pla ndoes not have to pre-approve a referral to an out-of-network provider for radiation therapy
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that you are unable to return home at this time.The Plan denied your request. The Plan says your needs could be met in a skilled nursing unit.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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 nothave to pre-approveacute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural steroid injection.You asked the Plan to pre-approvean epidural steroid injection. You say that the requested epidural steroid injection is medically necessary.The Plan denied your request. The Plan says the requested epidural steroid injection 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 an epidural steroid injection. Our reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer found the enrollee has neck, thoracic and low back pain. She has received 2 lumbar epidural steroid injections and bilateral SI joint injection. There is no physical exam detailing sensory, motor or reflex abnormalities in the upper extremity or thorax. There is no imaging of the cervical or thoracic spine submitted for review. The request is for a thoracic epidural steroid injection. There is a significant lack of clinical detail and imaging to support this request.  The request is 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 an epidural steroid injection have not been met.Therefore, we decided that the Plan does not have to pre-approvean epidural steroid injection.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvea 300mg Xolair injection (J2357) every 14 days.You asked the Plan to pre-approvethe Xolair injections. You say that this is medically necessary.The Plan denied your request. The Plan says that the requested use and dose is not supported.The Plan must follow Medicare rules. The rules say that Medicare may pay forunlabeled uses for FDA-approved 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 thePlan was correct in denying the request to pre-approve the Xolair injections. Our reviewer says that the Xolair injections are medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use and dose of Xolair is Food and Drug Administration (FDA) approved for the enrollee's diagnosis. Our reviewer also found that the documentation in the case file supports that the requested drug and dosing is medically reasonable and necessary for the enrollee 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 the Xolair injections have been met.Therefore, we decided that the Plan has to pre-approvea 300mg Xolair injection (J2357) every 14 days.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that you are not physically able to function in the home without aid. The Plan denied your request. The Plan says power operated vehicles are primarily covered for in-home use.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found it is not clear that your mobility deficit impairs participation in MRADLs in the home. It is not clear why you would be unable to use a walker or manual wheelchair in the home. The documentation does not reveal a detailed home assessment with measurements indicating that you could safely maneuver the wheelchair in the home. The documentation does not reveal that you require and will use this power operated vehicle in the home and that it will significantly improve MRADLS in the home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
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 LTACH services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been 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 enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The LTACH does not provide any services that are currently unavailable to the enrollee. The enrollee should remain in the current setting until they can be discharged to 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 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: 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 IRF services are medically necessary. 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 while the medical record documents a need for physical and occupational therapy, it
does not document a need for an intensive rehabilitation program. There are no medical needs requiring
inpatient admission. There are no complex nursing or rehabilitation needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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-approvethe back procedure (IntraceptIntraosseous Nerve Ablation System) (CPT Code 22899).You asked the Plan to pre-approvethe back procedure. You say that this procedure is medically necessary and the most effective treatment for the enrollee.The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain ad it is considered 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 back procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not fully support that the source of the chronic low back pain with radiation (along with right foot numbness) is significantly attributable to the basivertebral nerves. Medical literature does not support that thisis medically reasonable and necessary for the enrollee's specific condition as documented. The requested Intracept Intraosseous Nerve Ablation System is not medically necessary or the most effective treatment 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 back procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe back procedure (Intracept Intraosseous Nerve Ablation System) (CPT Code 22899)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CPAPMachine andHeated Humidifier.You asked the Plan to pre-approvethe DME. You say that you have a dental abscess that makes it painful to put on the CPAP mask and keep it on.The Plan denied your request. The Plan says the download from your machine showed that you used the machine on 2 nights out of 30, for at least 26 minutes. The Plan says that the criteria for continued coverage have not been met and the request is not considered 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 DME. Our physician reviewer found the download from your machine showed that you used your machine 2 nights (7 %) out of 30 for at least 26 minutes.Following Medicare coverage guidelines, specifically LCD L33718, to continue coverage beyond the first three-months trial rental of a CPAP machine, you must have used the machine at least 4 hours per night for 21 nights (70%) within a 30-day period. The review has determined that the criteria for coverage have not been met.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 DME have not been met.Therefore, we decided that the Plan does not have to pre-approvethe CPAP Machine and Heated Humidifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural steroid injection for the enrollee.You asked the Plan to pre-approvethe injection. You say that the enrollee has problems with the cervical spine.The Plan denied your request. The Plan says the records do not show that the limits are being followed.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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it does not make any sense to repeat a failed epidural steroid injection. The request is 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvean epidural steroid injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Dexcom6 therapeutic continuous glucose monitor (CGM).You asked the Plan to pre-approvea Dexcom 6 therapeutic continuous glucose monitor (CGM). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested item.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 you donot perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom 6 therapeutic continuous glucose monitor (CGM) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom 6 therapeutic continuous glucose monitor (CGM).