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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says 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 in the Medicare rules section 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a medical history that includes a left rib fracture and right trochanteric fracture with non-operative management. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a supervision to contact guard assist level with functional mobility. The enrollee required varying assist with activities of daily living. She was toe-touch weight bearing status. 

There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron.
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 ondansetron.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 tracheal laceration, respiratory failure and pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

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 medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found Keytruda is not FDA-approved for the treatment of ovarian cancer. The use is not supported by major drug compendia or medical literature. Data to support the use has shown poor results. The Keytruda is therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to provide an air ambulance transport to the facility that offers long term ventilator.
You asked the Plan to provide air ambulance transport from Florida to Ohio. You say that the enrollee is on a vent secondary to acute respiratory failure and needs to be transported by air ambulance to the facility. The Plan denied your request. The Plan says that they do not see that the services are not available in Florida.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 provide air ambulance transport from Florida to Ohio. Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation does support that the patient suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does support that the patient's condition is such that the time needed to transport a patient by ground, or the instability of transportation by ground, poses a threat to the patient's survival or seriously endangered the patient's health. The documentation does not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient however, the facility for transfer is the nearest appropriate facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transport from Florida to Ohio have been met. Therefore, we decided that the Plan has to provide an air ambulance transport to the facility that offers long term ventilator. 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 pay for inpatient services provided from June 27, 2019, through
July 5, 2019 with the reported principal diagnosis J18.9, pneumonia, unspecified organism.
You asked the Plan to pay for inpatient services provided from June 27, 2019, through July 5, 2019 with the reported principal diagnosis J18.9, pneumonia, unspecified organism. The Plan denied your request. The Plan says the discharge summary noted documentation of "Atypical chest pain", which was thought to be pleuritic in nature.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis J18.9, pneumonia, unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services provided with the reported principal diagnosis J18.9, pneumonia, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the review indicates that the enrollee presented to the facility on June 27, 2019 for treatment of chest pain. The chest x-ray obtained on June 27, 2019 indicated that there was "no focal airspace disease" and "no significant cardiopulmonary pathology seen". This was further confirmed by physician documentation in the discharge summary which stated, "Her chest x-ray demonstrated no evidence of any disease process". There was no follow-up imaging found on review. Therefore, there was insufficient objective clinical evidence to support a diagnosis of pneumonia. The review has determined that the principal diagnosis J18.9, pneumonia, unspecified organism was not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from June 27, 2019, through July 5, 2019 with the reported principal diagnosis J18.9, pneumonia, unspecified organism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).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 medically necessary.The Plan must follow Medicare rules. Medicare rules say that an expandable controller and harness with electronic connection are covered when specific criteria are met.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 not medically necessary. Our physician reviewer found the documentation does not show that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). He does not need to operate three or more powered seating actuators through the drive control, a separate display other electronic devices, or an attendant control. His strength and function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. The requested items are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
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 in the Medicare rules section. 

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 was admitted to the hospital for non-operative management of humerus fracture after a fall. He is now medically stable with no complex nursing or rehabilitation needs.

He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He may benefit from further therapy but does not require an intensive therapy program in an IRF. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says that the requested Keytruda is 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 Keytruda. Our reviewer says that the
requested Keytruda is medically necessary. Our physician reviewer found the enrollee is diagnosed with stage
3 renal cell carcinoma. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis.
However, the requested use of Keytruda is supported by one of the major drug compendia or by clinical
research that appears in a CMS-approved medical journal, Pembrolizumab versus placebo as post-nephrectomy
adjuvant therapy for patients with renal cell carcinoma: Randomized, double-blind, phase III KEYNOTE-564
study.
2021;39;15S. The documentation supports that the requested drug is safe and effective and otherwise
reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve
Keytruda.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation.
You asked the Plan to pre-approve non-emergency transportation. You say that the enrollee goes to dialysis three (3) times per week and is an amputee that does not drive. The Plan denied your request. The Plan says the enrollee's copayment for a single ambulance trip is $200 and this means that if the Plan approves ambulance transportation and the enrollee takes it, the enrollee will be paying $400 for each trip to dialysis. The Plan states the records show that although the enrollee has had amputations in both legs, they ambulate with a wheelchair. The Plan states they agree that the enrollee needs transportation to obtain medical services; however, they are able to sit in a wheelchair and the enrollee's community has access to transportation services curb to curb. The Plan states a van can be booked in advance of the enrollee's appointment that will pick them up with a wheelchair lift to transport the enrollee in their wheelchair to the enrollee's appointment and back.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency transportation. Our physician reviewer found the enrollee can use another form of transportation besides an ambulance. The enrollee's copayment for a single ambulance trip is $200. This means that if the Plan approves ambulance transportation the enrollee will be paying $400 for each trip to dialysis. The records show that although the enrollee has had amputations in both legs, the enrollee ambulates with the use of a wheelchair. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated for this enrollee. The documentation does not support that the enrollee needs the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport is medically reasonable and necessary 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 non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography, transthoracic (TTE), real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (Current Procedural Terminology (CPT) code 93306), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the requested TTE. Routine reassessment of LV EF in PAF is not indicated. Extensive notes were included but were remote back into 2018. No newer information.
The medical literature does not support an indication for surveillance echocardiography without changes in clinical status for this enrollee's condition. The review has determined that the items/services at issue in this case were not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve echocardiography, transthoracic (TTE), real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography (Current Procedural Terminology (CPT) code 93306), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are unable to take care of yourself and no one is available to be with you. The Plan denied your request. The Plan says you don't meet the requirements for IRF care, you can receive care in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec Tab 75mg ODT.
You asked the Plan to pre-approve Nurtec Tab 75mg ODT. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 Nurtec Tab 75mg ODT.
Benefits for Nurtec Tab 75mg ODT may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.