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

We decided that the Plan does not have to pre-approve Xiidra, 5% eye drops.
You asked the Plan to pre-approve Xiidra. You say that the enrollee has failed on Restasis. You also say that the enrollee improved after switching to Xiidra. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under 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 Xiidra, 5% eye drops.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNovolog.You asked the Plan to pre-approvethese 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 thatthe Plan does not have to pre-approveNovolog.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the endosteal implant. You say that you are in desperate need of the endosteal implant. You also say that you cannot afford to pay for this service. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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-approve a surgical placement of implant body: endosteal implant (D6010).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.

You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF system is not medically 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found the enrollee is with a history of asthma, anxiety/depression, diabetes and NYHA Class III congestive heart failure with preserved LV ejection fraction (LVEF 55-60%) requiring hospital admission. 

In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective 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. Therefore, 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 a CardioMEMS HF system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) on teeth #8 and 9.

You asked the Plan to pre-approve core buildup (D2950). You say that you would like the Plan to reconsider their 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 core buildup with dental code D2950 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) on teeth #8 and 9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID 19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the criteria for
admission to the Acute Inpatient Rehabilitation setting have not been met.

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 you do not require the intensity of services provided at an IRF. Specifically, you do
not show to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our
reviewer also found that your care needs can be met at a lower 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVIG.

You asked the Plan to pre-approve IVIG. You say that steroids are not ideal for this enrollee. You also say that you would like to use IVIG to see if the enrollee's platelet counts have a more manageable level so she can receive chemotherapy in a timely fashion. The Plan denied your request. The Plan says your request for IVIG does not meet the requirements for coverage.

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 IVIG. Our reviewer says that IVIG is not medically reasonable and necessary for the enrollee. Our physician reviewer found IVIG for immune thrombocytopenic purpurais indicated for patients who require a rapid, temporary increase in platelet count (eg, for urgent management of bleeding associated with thrombocytopenia or before an urgent invasive procedure). Our reviewer found that for enrollees this drug is used undergoing myeloablative chemotherapy TPO-RA are the treatment of choice. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve IVIG.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this drug is not covered
for the enrollee's condition by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Prolia.

Benefits for Prolia 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: Favorable

We decided that the Plan has to pre-approve CPAP (continuous positive airway pressure) device.

You asked the Plan to pre-approve CPAP device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested device is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that CPAP is covered for certain indications. 

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 CPAP device. Our reviewer says that the documentation does support that the requested CPAP machine is medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of obstructive sleep apnea (OSA). The documentation shows that the enrollee has been using CPAP for years. The enrollee required a new machine and therefore, had a new PAP titration in February 2020. This was not a new order for CPAP therapy, so the requirement of a follow-up visit to document benefit does not apply, because the enrollee was already benefiting from CPAP. Current compliance (July to October 2020) is demonstrated, exceeding Medicare minimum criteria of at least 70% of nights with at least 4 hours per night. Therefore, the enrollee meets criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPAP device have been met. Therefore, we decided that the Plan has to pre-approve CPAP (continuous positive airway pressure) device.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultra-lightweight wheelchair and associated accessories.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the documentation shows that this request is for the DME to be used outside the home.

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 DME have not been met. The documentation shows that the member currently has a Jazzy power chair. This request is for a manual wheelchair for outings and times when their power wheelchair is not working. The rules say that if the manual wheelchair is only for use outside the home, it will be denied as noncovered, no benefit, as the DME benefit requires use within the home for coverage eligibility. Therefore, we decided that the Plan does not have to pre-approve ultra-lightweight wheelchair and associated accessories.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the doctor believes the enrollee will significantly
benefit from Prolia. The Plan denied your request. The Plan says that the information submitted does not meet
the Plan's medical necessity guidelines for coverage.

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 Prolia. Our reviewer says that Prolia is
medically reasonable and necessary. Our physician reviewer found Zoledronic acid is likely to have adverse
effects given the estimated glomerular filtration rate of less than 35. Our reviewer also found that the creatinine
clearance is less than 35 mL/minute or evidence of acute kidney impairment: the use of Zoledronic acid is
contraindicated due to the increased risk of nephrotoxicity and lack of efficacy and safety data.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve
Prolia (J0897).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Valganciclovir.
You asked the Plan to pre-approve Valganciclovir. You say that the enrollee needs this medication at the time
of their discharge, and it is necessary to take home. The Plan denied your request. The Plan says this drug is not
covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Valganciclovir.
Benefits for Valganciclovir 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the doctor believes the enrollee will significantly benefit from Retacrit. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.
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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee. Our physician reviewer found this enrollee has a multifactorial anemia. The most recent hemoglobin was 10.6. Our reviewer also found that prior to initiation of Retacrit the hemoglobin should be less than 10. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance transport.
You asked the Plan to pay for the ambulance transport. You say that the enrollee lives alone and is a fall risk. You also say that the enrollee is trying to participate in physical therapy. The Plan denied your request. The Plan says ambulance transport to the skilled nursing facility is not medically necessary.
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 pay for the ambulance transport. Our reviewer says that an ambulance level of transport is not medically necessary. Our physician reviewer found there is no documentation of a medical condition that would require ambulance level of transportation and not a lower level such as wheelchair van. 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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for an ambulance transport.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the records do
not support the need for daily therapy on an inpatient basis.
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.
Continued services beyond December 10, 2020, were requested. 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, the
enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service
needs. Regarding rehab services, the enrollee was at a minimal assist level with functional mobility. She
required varying assist with activities of daily living. There are no identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. She does 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 continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs and loaner.
You asked the Plan to pre-approve the services. You say that you need the chair to perform your daily activities and to preserve a decorum of independence. You state that chair has fallen off a vehicle lift, but not due to your negligence. The Plan denied your request. The Plan says they will not pay for equipment which has been broken due to your carelessness, negligence or recklessness and it does not appear that you have been exercising reasonable care of your wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The Plan states they purchased the wheelchair for you in 2016 and this was repaired for you on July 10, 2020, when your wheelchair fell of your new van lift and damaged the motor. The Plan states they repaired your wheelchair for you again on September 9, 2020, when it fell off your van lift yet again. You are asking for the Plan to repair your wheelchair for you a third time as it has fallen off the van lift again. The Plan will not pay for equipment which has been broken due to your carelessness, negligence of recklessness. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs and loaner.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has no documented skilled therapy needs.
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, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at an independent to standby assist level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does 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 a skilled nursing facility (SNF) admission and services.