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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for coverage of this service have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that it is not a foregone conclusion that every lymphedema patient can use a limb-only, limited capacity, sustained high pressure basic pump. The Plan denied your request. The Plan says there is no failure of a four week trial of conservative therapy or E0650/E0651.
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 device. 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 reveal clear objective physical exam findings of lymphedema of the chest, trunk, or abdomen. Swelling or congestion of the truncal area does not clearly indicate evidence of true lymphedema. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump or evidence of a sufficient trial and failure of a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection, LED lights and a power seat elevation feature for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested durable medical equipment items not covered for member's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. 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 expandable controller, harness and electronic connection are not considered medically reasonable and necessary in this case. The documentation does not reveal that the patient requires other types of proportional input devices or non-proportional input devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The documentation reveals that the patient has sufficient upper extremity strength that he should be able to operate any power options on a wheelchair through their own individual switches. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for an expandable controller, harness and electronic connection. We looked at this physician's review, the file, and Medicare rules. A power seat elevation feature and LED lights are not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection, LED lights and a power seat elevation feature for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips (15260) provided December 16, 2019.
You asked the Plan to pay for the full thickness graft. You say that please review the attached medical records to substantiate billing for the CPT code 15260. The Plan denied your request. The Plan says the maximum frequency per day for CPT code 15260 is one unit. The plan has reprocessed and paid for one unit.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 15260 is 1. You billed for 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the full thickness graft have not been met. Therefore, we decided that the Plan does not have to pay for full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips (15260) provided December 16, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve GAZYVA 1000MG/40ML Solution (CPT Code J9301).
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says that the medication is not necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 the medication. Our physician reviewer
found that the Plan should approve first line obinutuzumab + venetoclax for CLL per NCCN compendia
obinutuzumab and venetoclax.
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 medication have been met. Therefore, we decided that the Plan has to preapprove
GAZYVA 1000MG/40ML Solution (CPT Code J9301).
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 you need more rehab therapy to reach a
baseline. The Plan denied your request. The Plan says you do not require daily skilled services in a SNF.
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 physician reviewer
found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs
were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a
moderate to maximal assist level with functional mobility. You require varying assist with activities of daily
living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 Mvasi and Tecentriq.
You asked the Plan to pre-approve Mvasi and Tecentriq. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drugs are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Mvasi and Tecentriq. Our reviewer says that the documentation does support that the requested drugs are medically reasonable and necessary. Our physician reviewer found the documentation supports that the requested drugs are FDA approved for the enrollee's diagnosis. Treatment of unresectable or metastatic hepatocellular carcinoma (in combination with bevacizumab) is indicated in enrollees who have not received prior systemic therapy. Therefore, the enrollee meets criteria for the requested drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mvasi and Tecentriq have been met. Therefore, we decided that the Plan has to pre-approve Mvasi and Tecentriq.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture
after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission.
There are no complex nursing or rehabilitation needs. 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. 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. Our physician
reviewer found that your condition does not meet Medicare criteria for IRF 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for cardiogenic shock, ventricular septal defect, and myocardial infarction. Medical conditions
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or
rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a sternal fracture and rhabdomyolysis after a motor vehicle accident. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone (J1100), Pembrolizumab (J9271), Pemetrexed (J9305), Carboplatin (J9045), Palonosetron (J2469), and Aprepitant (J0185).
You asked the Plan to pre-approve Dexamethasone, Pembrolizumab, Pemetrexed, Carboplatin, Palonosetron, and Aprepitant. You say that the treatment ordered meets NCCN guidelines. The Plan denied your request. The Plan says the off-label use of these drugs for the enrollee's condition are not medically accepted per Medicare rules, and are not covered based on available information.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Dexamethasone, Pembrolizumab, Pemetrexed, Carboplatin, Palonosetron, and Aprepitant. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Our physician reviewer found Pemetrexed is not recommended for squamous cell histology, and there are no driver mutations, anaplastic lymphoma kinase (ALK), or EGFR. Our reviewer found that the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer also found that the use of these drugs is not listed as not indicated, not supported or not recommended in any of the 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 Dexamethasone, Pembrolizumab, Pemetrexed, Carboplatin, Palonosetron, and Aprepitant have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone (J1100), Pembrolizumab (J9271), Pemetrexed (J9305), Carboplatin (J9045), Palonosetron (J2469), and Aprepitant (J0185).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colostomy Supplies (Supplies for an artificial opening in the abdominal wall).

You asked the Plan to pre-approve the supplies. You say that the supplies are necessary. The Plan denied your request. The Plan says they approved the maximum amount of supplies according to the Medicare rules.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. The health plan has agreed to provide coverage on October 2020 for one year. The number of supplies approved was 240 (20 per month). The standards state that maximum quantity of supplies per month should not exceed 20 per Month (240 per Year). Therefore, we decided that the Plan does not have to pre-approve Colostomy Supplies (Supplies for an artificial opening in the abdominal wall).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for chest pain and was treated for a myocardial infarction. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and Avastin.
You asked the Plan to pre-approve the requested drugs. You say that the enrollee responded to the treatment during a clinical trial. The Plan denied your request. The Plan says studies have not proven the drug combination are helpful for uterine cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested drugs. Our physician reviewer found that the requested use of Avastin and Keytruda FDA-approved for the enrollee's diagnosis. There is no role for Keytruda and Avastin for this disease per compendia or literature. The documentation does not support that the requested drug is safe and effective, and otherwise reasonable and 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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda and Avastin.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amlodipine besylate-benazepril tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are requesting coverage. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 amlodipine besylate-benazepril tablets.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.