Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says currently, Superion spacer devices for interspinous decompression are still being studied to see if this treatment is reasonable and necessary to be covered by Medicare.
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 device is experimental, and more research is needed to show safety and efficacy. 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 insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says this admission cannot be approved.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level and 60 feet x 2 mod assist ambulatory status do not require or indicate that this therapy must be in an IRF with an intensive level program.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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Plavix 75mg tablet for the enrollee.You asked the Planto pre-approvethe tablet. You say that this is medically necessary.The Plan denied your request. The Plan saysthe enrollee does not have a pharmacy 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 Plandoes not haveto pre-approvePlavix 75mg tablet for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation and alveoloplasty.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.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvegingival irrigation and alveoloplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea life alert system.You asked the Plan to pre-approvethese services. You say that you are unable to get up on your own if you fall.The Plan denied your request. The Plan says the item is not covered.The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.The item at appeal is a medical life alert system. While this item may be of benefit to you, it is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvea life alert system
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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on May 8, 2020 with a fall and right ankle injury. You had surgical repair of the ankle fracture on May 9, 2020. You need assistance with eating, grooming, bathing, dressing, and toileting. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do 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: Drugs
Decision: Favorable

We decided that the Plan has 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 that 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 medically necessary. Our physician reviewer found the enrollee has early-stage non-small cell lung cancer (NSCLC) in 2016 treated with surgery alone. She has a recurrent left-sided lung mass felt to be likely recurrent, but possibly a new primary. It is unable to be biopsied and, to cover for the possibility of a squamous cell lung cancer, the choice was made to use taxol rather than pemetrexed to cover both. The combination of carboplatin/taxol with Keytruda is the standard first line chemotherapy regiment and is reasonable and 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 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: 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 the SNF services. You say that the records provided support the need for additional care in a SNF.The Plan denied your request. The Plan says the enrollee has reached the 100th SNF day as of May 14, 2020.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 26 -May 14, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital care.You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for inpatient psychiatric care is correct.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient psychiatric care. Our physician reviewer found based upon review of the records provided, it was not expected that this enrollee would improve within a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions, and was not showing any behavioral issues or withdrawal symptoms. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The Plan's denial of inpatient psychiatric services is appropriate. It does not appear that active treatment was taking place. It does not appear that the services were reasonable expected to improve the enrollee's condition or for the purposes of diagnosis. There is not an individualized treatment plan in the record; however, the entirerecord is not present. It does appear that treatment was supervised and evaluated by a physician. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital care.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections (J7321).
You asked the Plan to pre-approve Supartz FX. You say that the Supartz FX is medically necessary. The Plan denied your request. The Plan says a trial of plan preferred viscosupplements is required before alternatives can be considered.
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 Supartz FX. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the record does not show a failed trial of the plan preferred agents, Orthovisc and Monovisc, or any reason why the plan preferred agents would be ineffective or unsafe. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections (J7321).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 28 fractions of intensity modulated radiation therapy (IMRT) for breast cancer.You asked the Plan to pre-approve the IMRT services. You say that adequate PTV coverage within acceptable critical structure constraints was not possible with a 3D treatment plan and IMRT is required.The Plan denied your request. The Plan says that the requested IMRT is not reasonable and necessary under Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 IMRT services. Our reviewer says that the requested IMRT services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has stage II breast cancer, status-post mastectomy with a positive anterior margin. IMRT is allowed for postoperative radiation when there is a positive margin according to medical literally and accepted guidelines.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 IMRT services have been met.Therefore, we decided that the Plan has to pre-approve28 fractions of intensity modulated radiation therapy (IMRT) for breast cancer.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by a non-participating provider.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care at a skilled nursing facility (SNF).You asked the Plan to pre-approve the continued SNF care. You say that the records provided support the need for a continued SNF stay.The Plan denied your request. The Plan says the enrollee's 100-day benefit has been exhausted.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from February 11 -May 22, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approve continued care at a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty.You asked the Plan to pre-approvethe kyphoplasty. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records provided do not show that the member has a fracture that is less than 6 weeks old.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 kyphoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the member's fractures are acute within 6 weeks as documented by an MRI within 30 days.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 kyphoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvekyphoplasty.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan does not have to pre-approve Zarxio. We have also decided the Plan has to preapprove
Kadcyla for the enrollee.
You asked the Plan to pre-approve Zarxio and Kadcyla. You say that these drugs are medically necessary for
the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for the drugs requested
are not met.
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 Zarxio and Kadcyla. Our reviewer says that at issue is coverage of Zarxio and Kadcyla. The
records show the enrollee has a diagnosis of Malignant neoplasm of overlapping sites of left female breast,
grade 2 invasive lobular (+, PR-, HER-2+). The enrollee completed 6 rounds of TCHP with good shrinkage.
The enrollee completed one dose of maintenance trastuzumab. On May 18, 2020, the enrollee received
Pertuzumab and Trastuzumab. Our physician reviewer say that the medical records do not support that Zarxio
is medically reasonable and necessary in this case. The documentation does not support that the enrollee is at
moderate or high risk of febrile neutropenia. The documentation does support that Kadcyla is medically
reasonable and necessary in this case. Kadcyla is indicated for the treatment of HER2-positive breast cancer, as
adjuvant monotherapy for enrollees with residual disease after neoadjuvant taxane and trastuzumab-based
treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zarxio are not met. It is also our decision that Medicare criteria for Kadcyla are
met. Therefore, we decided that the Plan is required to provide coverage for Kadcyla but is not required to
provide coverage for Zarxio for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.You asked the Plan to pre-approve a raised toilet seat. You say that you disagree with the denial.The Plan denied your request. The Plan says the item is not covered.The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 30, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, a Vitamin D assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says the mobility deficit can be appropriately addressed with a manual wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the criteria have not been met for a power mobility device. The documentation indicates the enrollee has a personal mobility deficit but the documentation is not clear that it impairs participation in MRADLs. There is no objective physical examination included in the documentation that supports that the enrollee is unable to help his mobility deficit by the use of a walker, cane or manual wheelchair. There is no home evaluation included in the documentation indicating that the enrollee's home is suitable for a PMD.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.