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

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that the enrollee has tried Remicaid. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that the criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of Stelara and either Remicade or Inflectra before they will approve the requested drug. While the enrollee has tried Remicade, the record does not show that she has tried Stelara or that Stelara would likely be less effective or have adverse effects 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services after May 16, 2021.
You asked the Plan to pre-approve continuation of inpatient psychiatric services after May 16, 2021. You say that the enrollee needs to be monitored with continued inpatient treatment and stabilization. The Plan denied your request. The Plan says the enrollee can be treated as outpatient.
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 continuation of inpatient psychiatric services after May 16, 2021. Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of May 17, 2021 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This patient was not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient psychiatric services after May 16, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services after May 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Keytruda is correct, because Keytruda in this drug combination is only indicated for squamous cell disease which the enrollee is not diagnosed with.
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 enrollee does not meet the Medicare criteria for use of Keytruda. Our physician reviewer found in this case the enrollee has metastatic non-small cell lung cancer. The specific requested regimen is not supported in Medicare-approved compendia for the histology of the enrollee's cancer. Therefore, this drug cannot be recommended. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), a preventive procedure (D1999), and two pontics (D6240 x2).
You asked the Plan to pre-approve the core buildups, preventive procedure, and pontics. You say that you the enrollee needs a new bridge, and you recommend these services. The Plan denied your request. The Plan says these services are not covered under the enrollee's plan.
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 two core buildups, including any pins when required (D2950 x2), a preventive procedure (D1999), and two pontics (D6240 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar Decompression (PILD) procedure (0275T).
You asked the Plan to pre-approve the PILD procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. There is no documentation that the enrollee is part of a clinical study. Based on this information, we decided that Medicare rules for coverage of the PILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar Decompression (PILD) procedure (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a suction socket (L5647) and an alignable system (L5910).
You asked the Plan to pre-approve these items. You say that these components are medically necessary. The Plan denied your request. The Plan says the requested components are not reasonable or necessary for a preparatory prosthesis.
The Plan follows Medicare rules. Medicare rules say that when an initial below knee prosthesis or a preparatory below knee prosthesis is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 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 a suction socket and an alignable system. Our reviewer says that the requested components are not medically necessary. Our physician reviewer found that there is no documentation provided that indicates the request for a suction socket and an alignable system for the preparatory prosthesis meets the criteria for coverage as the preparatory prosthesis is a
non-alignable system.
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 suction socket and an alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve a suction socket (L5647) and an alignable system (L5910).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested drug is to be used for an unsupported off-label use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the requested treatment is not medically reasonable and necessary. Our physician reviewer found that the requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. Iron deficiency anemia does not meet the criteria for Retacrit. Furthermore, this use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 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 treatment with Retacrit (Q5106).
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 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 the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen (15) hours per week of rehabilitative services with regular physician evaluation. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a whole-body bone scan (78306).
You asked the Plan to pre-approve a whole-body bone scan. You say that this is medically necessary. The Plan
denied your request. The Plan says that a more localized study would be more appropriate.
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 a whole-body bone scan. Our reviewer
says that the requested services are considered medically reasonable and necessary in this case. Our physician
reviewer found the records show that the enrollee has a painful knee prosthesis that may be loose. The x-rays
are normal. The bone scan will show infection or loosening of the prosthesis at this time. It is appropriate as the
next step in the workup.
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 whole-body bone scan have been met. Therefore, we decided that the Plan has
to pre-approve a whole-body bone scan (78306).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need acute rehab. 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 you were admitted to the hospital for lung surgery due to cancer. You were discharged to a skilled nursing facility on May 19, 2021. You are medically stable with 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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. 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after April 28, 2021.
You asked the Plan to pre-approve SNF care. You say that continued skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee has exhausted their skilled nursing facility benefit.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before April 28, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care after April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390), portable oxygen system (E0431) and portable oxygen (E0443) for the enrollee.
You asked the Plan to pre-approve these services. You say that the member needs oxygen while flying because of congestive heart failure and atrial fibrillation. The Plan denied your request. The Plan says that the enrollee does not meet criteria for approval of these services.
The Plan follows Medicare rules. Medicare rules say that home oxygen can be covered if the LCD criteria have been 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 these services are not medically reasonable and necessary for the enrollee. The patient has atrial fibrillation and hypertension. Home oxygen was recommended to be used at a 2L/minute amount while flying/traveling by plane. She had a seizure on a plane in the past due to lack of oxygen. PO2 was recently tested at 81.9 mmHg, SO2 at 85.3% (both normal). The records do not clearly show that the patient has chronic lung condition that is severe enough to warrant portable oxygen. There was no other diagnosis which would justify this request. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an oxygen concentrator (E1390), portable oxygen system (E0431) and portable oxygen (E0443) for the enrollee.
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 you would be able to recover much faster with inpatient rehab. The Plan denied your request. The Plan says your medical complexity care is low, and you do not require an interdisciplinary approach to rehab care.
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 physician reviewer found that you were admitted to the acute care hospital for lower extremity weakness, falls and cellulitis. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehab therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires which are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899).
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure has not been shown to be safe and effective.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for back pain. More research is needed to show it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that this service is medically necessary. The Plan denied
your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the drug
is not medically reasonable and necessary. Our physician reviewer found in this case, the enrollee has psoriasis
vulgaris. The record indicates that the enrollee has been in a research study utilizing Otezla. The enrollee has
not tried and failed two of the Plan's recommended step therapy drugs. The requested drug is a new start. he
elements of the coverage rule are not satisfied. The requested service cannot be recommended
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya.