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

We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan of the brain.
You asked the Plan to pre-approve the FDG brain PET scan. You say that this imaging is needed to see if the enrollee has Alzheimer's disease. The Plan denied your request. The Plan says this imaging is only covered to aid in differential diagnosis for enrollees who meet criteria both for AD and FTD.
The Plan follows Medicare rules. Medicare rules say that FDG PET imaging of the brain is covered for those with dementia who meet criteria for both FTD and AD. 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 FDG brain PET scan. Our reviewer says that the requested imaging is not shown to be medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 82-year-old man with short-term memory loss for the past year. The enrollee's long-term memory is intact. He drives, cooks, and takes care of his finances without difficulty. It has not been established that the enrollee has a recent diagnosis of dementia and documented cognitive decline of at least 6 months, and meets diagnostic criteria for both Alzheimer's disease (AD) and fronto-temporal dementia (FTD). It has not been demonstrated that the enrollee has been evaluated for specific alternate neurodegenerative diseases or other causative factors, but the cause of his clinical symptoms remains uncertain. 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 FDG brain PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan of the brain.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percocet.
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 covered.
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 Percocet.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).
You asked the Plan to pre-approve home ventilator. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our physician reviewer found coverage criteria for a home ventilator are not met. This patient has chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), and likely has chronic hypercarbic respiratory failure. The patient may qualify for BiPAP, however Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode of support that has been ordered. There is no evidence of BiPAP failure, and the patient has been treated successfully with BiPAP during hospitalizations. A home ventilator is not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to regain strength to comfortably ambulate and transfer alone. The Plan denied your request. The Plan says that it is feasible to meet member's needs at a lower level of care.
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 the enrollee's 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 for the enrollee.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Eylea.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the step therapy requirement is not 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a history of diabetes with bilateral proliferative retinopathy. He complained of worsening vision in the right eye on August 12, 2020 since his previous visit. The examination demonstrated right macula intraretinal hemorrhage and right macular edema, confirmed with optical coherence tomography. Diagnosis was clinically significant macular edema for the right eye. Eylea is medically necessary for the enrollee, as the records support that it would be superior to the required drug, Avastin. He has diabetic macular edema with visual acuity of 20/200 in the right eye and Eylea is superior to Avastin for the treatment of this condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Eylea.
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: Inpatient Hospital
Decision: Unfavorable

We are dismissing your case. The Plan agreed to pre-approve the IRF care. Therefore, there is no need for a coverage decision.
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 covered.
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 services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the CardioMEMs heart failure monitor.
You asked the Plan to pre-approve the CardioMEMS monitor. You say that this is a beneficial treatment which would reduce hospitalization for this enrollee. The Plan denied your request. The Plan says this is still considered experimental.
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 CardioMEMS monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. As such, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMS monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the CardioMEMs heart failure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurosurgery consultation to be provided outside of the Plan's service area.
You asked the Plan to pre-approve neurosurgery consultation. You say that you need this treatment to get well enough to travel back to the Plan's service area so you can get treatment there. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 neurosurgery consultation. Our reviewer says that the requested consultation visit does not meet the Medicare criteria for coverage of urgent, out-of-area care. Our physician reviewer found you could not have foreseen requiring this treatment prior to leaving the Plan's service area. You underwent magnetic resonance imaging (MRI) in the emergency department which showed a degree of spinal stenosis, this is a new problem. There was no evidence of a neurological emergency that requires immediate surgical intervention. Rather, prior to consideration of surgery in such cases, patients are advised to attempt all conservative (non-surgical) treatment options. You have not begun this process yet, so a surgical consultation would be premature in this case. Your condition is not one that requires any degree of urgent surgical intervention. You can first attempt to manage your pain conservatively until you return to the Plan's service area/your home region.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurosurgery consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurosurgery consultation to be provided outside of the Plan's service area.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of ipilimumab and nivolumab.

You asked the Plan to pre-approve ipilimumab and nivolumab. You say that you believe the enrollee will significantly benefit from these drugs. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because these drugs are not indicated for use in the enrollee's circumstances.

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 ipilimumab and nivolumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested ipilimumab and nivolumab. Our physician reviewer found the requested combination of drugs is not approved by the Food & Drug Administration (FDA) for use in the enrollee's condition. This combination of drugs is also not supported by any of the Medicare-approved drug compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ipilimumab and nivolumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of ipilimumab and nivolumab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for self-injection.
You asked the Plan to pre-approve the Dupixent. You say that this is necessary to treat the enrollee's condition. The Plan denied your request. The Plan says this drug is self-injected and 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 Dupixent for self-injection.
Benefits for the Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee had a CT scan of the
abdomen/pelvis on May 29, 2020 that demonstrated a hematoma of the abdominal wall. The radiology report
states there is evidence of an oblong hyperdense fluid collection within the right inferior lateral abdominal wall
adjacent to the right anterior inferior 11th and 12th ribs most likely representing a hematoma, but malignancy
cannot be excluded. The follow-up CT scan is reasonable and medically necessary for monitoring.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
a computed tomography (CT) scan of the abdomen/pelvis.
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: 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 needs more rehab for the knee and she has not been able to get adequate therapy in the nursing home due to staffing issues. This has caused her to lose function since entering the nursing facility. The Plan denied your request. The Plan says the enrollee is not strong enough to participate in three daily hours of therapy.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for treatment of pneumonia associated with COVID 19. Medical problems are stable and no longer require inpatient management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although physical and occupational therapy is appropriate for the patient's clinical condition, this therapy does not require an intensive rehabilitation program. There is not a reasonable expectation that this patient 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 not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee has low back pain radiating through the nerves (radiculopathy) and is currently medically stable. Her pain is controlled and she needs assistance with some activities of daily living. She does not have complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member's current needs are being met in the 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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
appears to require additional acute care services at this time, however, based on the gradual improvement noted
in recent notes, it is unlikely he will need acute care services for more than 24 days. The enrollee does not
require services at the LTACH that are not already available at the current facility. The patient should be able
to transfer to a lower level of care once antibiotics are completed and feeding is stabilized. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that disposable drug delivery systems (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. We looked at the file and Medicare rules. The item at issue is an Omnipod described by code A9274. This item is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an Omnipod.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.