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

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the SNF admission for the enrollee does not meet the criteria.
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 the SNF admission. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis addition (L2385) provided to the enrollee on
April 7, 2020.
You asked the Plan to pay for the orthosis. You say that the enrollee needs the device. The Plan denied your
request. The Plan says there is not documentation or a proof of delivery or a physician order to verify the billed
code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order, proof of delivery, or relevant medical records which
support medical necessity for the supplies provided in this case. This code is not on the documentation,
therefore cannot be verified. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis
addition (L2385) provided to the enrollee on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0651).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says there is no new 4-week trial as described in LCD. Therefore, LCD criteria has not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy with documentation demonstrating a failed response. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular clearly documented conservative therapy including exercise, elevation, and compression garments. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0651).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that it is medically necessary to continue physical therapy. The Plan denied your request. The Plan says more therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Eylea (aflibercept).
You asked the Plan to pre-approve Eylea. You say that the enrollee is failing Avastin and needs Eylea. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee does not meet the criteria for this drug.
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 Eylea. Our reviewer says that the enrollee meets the Medicare criteria for use of Eylea. Our physician reviewer found Eylea is approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. Examination of the retina showed severe non-proliferative diabetic retinopathy on the right with center-sparing diabetic macular edema and severe non-proliferative diabetic retinopathy on the left with center-involving diabetic macular edema. The enrollee has not responded to Avastin. The documentation supports that Eylea is expected to be safe and effective, and otherwise reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve use of Eylea (aflibercept).
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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 does not require services at the proposed LTACH that are not available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Completion of acute care services can be performed at the current facility and the enrollee can be transferred to a lower level of care when required.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Basaglar Kwikpen.
You asked the Plan to pre-approve the Basaglar Kwikpen. 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 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 the Basaglar Kwikpen.
Benefits for the Basaglar Kwikpen 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 15, 2020.
You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says continued SNF care is not medically necessary.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF beyond the last covered date. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond August 15, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that the enrollee needs the medication to strengthen her bones. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have a history of an osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. The documentation does not include a medication trial or contraindication to zoledronic acid. Without the support of the documentation, Prolia is not approved, as the Plan's required drug would not be contraindicated or less 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA)
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee will be eligible for the next RFA in January 2021.
The Plan must follow Medicare rules. The rules say that RFA is covered twice per calendar year.
The case file shows that there were two prior RFA sessions in January 2020. This service is only allowed by
Medicare twice a year. 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 a repeat radiofrequency
ablation (RFA)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 1, 2019 to April 1, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not bill with the appropriate home health data.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, This claim has been billed with a HIPPS code that indicates the use of non-routine supplies and there are no non-routine supplies billed.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 1, 2019 to April 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF admission is not medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided,
you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled
professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a
SNF. You do not have complex wound care or other ongoing SNF level skilled nursing needs. Your functional
level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You also do
not require skilled nursing or skilled therapy services daily. We looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF)
services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen for the enrollee. 
 
You asked the Plan to pre-approve Neupogen. You say that this drug is necessary for the enrollee. The Plan 
denied your request. The Plan says because the enrollee is participating in a clinical trial, this request and or 
expense must be submitted to Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Original Medicare pays for the costs for items 
and services for enrollees in a clinical trial. The records provided show the enrollee is participating in a clinical 
trial. Therefore, we decided that the Plan does not have to pre-approve Neupogen for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care from December 7, 2019 to 
December 14, 2019 and from December 19, 2019 to January 5, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says skilled services were not medically necessary. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found from a nursing perspective, the beneficiary 
received oral and topical medications and insulin.  The beneficiary had stable vital signs. She was treated for 
insomnia, pain and anxiety.  She tolerated a fluid restriction.  
 
Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By 
the dates in question, the beneficiary continued to receive therapy at a non-skilled level of twice weekly. The 
beneficiary did 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility care from December 7, 2019 to December 14, 2019 and from December 19, 
2019 to January 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Raptor 3-wheel scooter.
You asked the Plan to pre-approve the requested scooter. You say that you need a scooter that has a 3-inch
clearance. The Plan denied your request. The Plan says the requested scooter is not covered by Medicare or
your plan.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Furthermore, the requested scooter is not a
device that is covered by Medicare or your plan. Therefore, we decided that the Plan does not have to preapprove
a Raptor 3-wheel scooter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee needs inpatient level of care. The Plan denied your request. The Plan says that the denial of authorization for inpatient level of care is correct, because the enrollee can be treated at the observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient level of care are met in this case. Our physician reviewer found at the time of inpatient admission the admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for acute inpatient hospital care.
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 Latuda. 
 
You asked the Plan to pre-approve Latuda. You say that the enrollee's condition is controlled on the 
medication. The Plan denied your request. The Plan says the drug is not covered for the enrollee's condition by 
the Part B plan. 
 
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 Latuda.  
 
Benefits for Latuda 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on August 19, 2020 with altered mental status and a chest x-ray showing masses and possible pneumonia. She 
received oral and inhaled medications and had stable vital signs. She received physical therapy in the hospital 
and needs maximum assistance with functional mobility. She has no skilled nursing or skilled therapy needs. 
She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does 
not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.