Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvereplacement of a lower limb prosthesis.You asked the Plan to pre-approvethe prosthesis replacement. You say that you have not had any success in getting the prosthesis to fit functionally and feel that it cannot be fixed by the prosthetic provider. You wish to go to a different provider to have a new prosthesis made since the current one is not repairable.The Plan denied your request. The Plan says in this case, you have not presented to theoffice to allow for an evaluation to judge the reparability of the prosthesis. It is noted that only minor adjustments can be made in the home and a full repair evaluation requires an office visit.The Plan must follow Medicare rules. Medicare rules say that a replacement prosthesis is covered only when one of the above referenced criteria are met. In this case, there is no evidence of a change in your physiological condition that cannot be addressed by adjustments provided in the prosthetist's office. There is also no evidence of irreparable wear or that the condition of the device is such that repairs would cost more than 60% of the cost of replacement. Although it is noted that problems have continued to arise after several adjustments, none of these evaluations have shown that repair is not possible. Replacement of a prosthesis which is less than one year old is not covered in this clinical situation.Therefore, we decided that the Plan does not have to pre-approvereplacement of a lower limb prosthesis.
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 LTACH care would be the best option in
this case. The Plan denied your request. The Plan says an LTACH is not able to provide any materially
different service from those available at the current facility.
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 incentive spirometer and aspiration precautions,
surveillance laboratory studies, tube feedings, 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. 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.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical therapy and occupational therapy, but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level 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: Inpatient Hospital
Decision: Unfavorable

Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 CFR422.101.The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).  The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.Explanation of decisionWe decided that the Plan does not haveto pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH services.The Plandenied your request. The Plan says an LTACH is not able to provide any service that cannot be provided in the current facility. Therefore, LTACH care 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for influenza and pleural effusions. The enrollee has had a chest tube placed and is receiving antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the 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 LTC 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 the LTACH services have not been met.Therefore, we decided that the Plan does not haveto 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 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 transfer to a long-term acute care facility is not appropriate at this time.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 is currently undergoing treatment at an ACH for pneumonia complicated by effusions and a pneumothorax. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has undergone lung decortication and had chest tubes placed.  The enrollee is tolerating daytime ventilator weaning with ventilator support overnight. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the 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, 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 admission to a long term acute care hospital (LTACH).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveDexamethasone tablets 4mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis falls under Medicare Part D coverage, and the enrollee does not have this coverage.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 Plandoes not haveto pre-approveDexamethasone tablets 4mg for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0676).You asked the Plan to pre-approvea pneumatic compression device. The Plan denied your request. The Plan says this is not a covered item.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0676)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that your therapy needs could be met at a lower level of care with intermittent intensity with home health.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 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 skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this should be covered. The Plan denied your request. The Plan says that the documentation does not show that the enrollee has tried and failed infliximab or adalimumab.
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 Entyvio. Our reviewer says that Entyvio is medically necessary. Our physician reviewer found the enrollee has evidence of moderately active Ulcerative colitis. She has been treated with an appropriate trial of a corticosteroid (Budesonide) and a 5-Aminosalicylate (Mesalamine). The enrollee has had symptoms suggesting a flare of her Ulcerative colitis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have been met. Therefore, we decided that the Plan has to pre-approve Entyvio (J3380).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEstradiol 1mg tablets.You asked the Plan to pre-approveEstradiol. You say that the drug at issue is medically necessary.The Plan denied your request. The Plan says coverage for self-administered drugs is not available under Part Bmedical benefits for Estradiol.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 MedicarePart B.Therefore, we decided that the Plan does not have to pre-approveEstradiol 1mg tablets.Benefits for Estradiolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you have not had previous treatment, a contraindication, or intolerance to Orthovisc and Monovisc.
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 requested services. Our physician reviewer found that you have a diagnosis of primary osteoarthritis of the right and left knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that you have tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that The Plan denied your request. The Plan says the request does not meet the definition of medical necessity by generally accepted standards of medical practice.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. Medicare rules also say that for coverage to be considered, information must be submitted to confirm that Medicare criteria have been met. We looked at the file and Medicare rules. The case file shows that no medical records were provided to support the medical necessity of the requested CT scan. The case file shows that the Plan made reasonable attempts to obtain this necessary documentation. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-one (J7326).
You asked the Plan to pre-approve Gel-one. You say that the requested medication is medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 Gel-one. Our reviewer says that the exception is not medically necessary. Our physician reviewer found the provided medical records do not indicate that you have tried and failed the required drugs. The provided medical records also do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-one (J7326).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRI of the upper extremity for the enrolleet.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested services have been found to not be medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags apparent in the notes concerning the enrollee's physical exam. There is a referral to PT and a note from the Ortho concerning MRI in the "future" which implies such a study might be necessary if PT is ineffective. At this point there is no medical necessity for MRI prior to the ordered PT.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefoot orthotics.You asked the Planto pre-approvefoot orthotics. You say that this is medically necessary.The Plandenied your request. The Plansaysthe request is not approved because the requested orthotic is not being used as an integral part of a covered brace.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan providescoverage of orthotics for your condition.Therefore, we decided that the Plandoes not haveto pre-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approv elong term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that LTACHs are better equipped for long term vent weaning and for the care of certain patients such as this one.The Plan denied your request. The Plan says there is no evidence that an LTACH can provide any type of patient with superior services over a non-LTACH facility.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 patient is currently undergoing treatment at an ACH following surgery for gastroesophageal cancer. The enrollee's post-operative course was complicated by respiratory failure and a pulmonary embolus, for which the enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is currently tolerating tracheotomy collar trials/ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the 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 LTC 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.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 Entresto.Benefits for these servicesmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.