Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the services you need are being offered at the inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you were admitted to an acute rehabilitation facility (IRF) after a lumbar fusion. You are walking 75 to 90 feet with a rolling walker with contact guard assistance and are moderate assist for transfers and some activities of daily living. You are reported to be having issues with lower extremity lymphedema and cellulitis, urinary retention, and pain. Records indicate you are tolerating and benefitting from therapy in the IRF. Continued care in the acute inpatient rehabilitation facility is appropriate, and endorsed by the Plan, until you are stable to transfer to a lower level of care. Therefore, the requested services are not 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 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 Keytruda for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug in this case requires therapy in combination with either albumin-bound paclitaxel, paclitaxel, or gemcitabine with carboplatin for PD-L1 positive disease.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of  metastatic, triple negative breast cancer. The record indicates that the requested drug is being used as first line therapy. The record does not indicate the PDL-1 status. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied.   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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a below knee alignable system addition (L5910) and lower extremity design socket addition (L5632).  You asked the Plan to pre-approve the prosthetic additions. You say that the items are medically necessary. The Plan denied your request. The Plan says your current prosthesis includes a below knee alignable system addition with no documentation of damage and that you have a Transtibial amputation, the brim design socket addition is for a Symes amputation.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a prosthetic with a below knee alignable system addition. The requested addition serves the same purpose as the one you currently have. Additionally, a Symes prosthetic addition is not medically necessary as you do not have that type of amputation. Therefore, we decided that the Plan does not have to pre-approve a below knee alignable system addition (L5910) and lower extremity design socket addition (L5632).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional ostomy supplies.

You asked the Plan to pre-approve the supplies. You say that this is medically necessary. The Plan denied your request. The Plan says the explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary's medical record.

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 supplies. Our reviewer says that the requested additional supplies are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided report a tendency to have intermittent leakage as the enrollee's ileostomy pouch becomes full, but the records do not contain a specific medical justification for the additional requested quantity of ostomy supplies. 

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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve additional ostomy supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface (BiPAP) (CPT code(s): E0562 and E0470).

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 Medicare rules have not been met. The Plan states they did not receive a qualifying blood gas study from your provider, did not receive a spirometry test or a sleep study from your provider.

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 DME. Our physician reviewer found the available documentation in the case file does not support that the coverage criteria for a respiratory assist device with bi-level pressure capability, as established by LCD L33800, have been met 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 the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface (BiPAP) (CPT code(s): E0562 and E0470).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 there are no complex nursing or rehabilitation needs. While you do have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee is unable to do daily activities for independent living. The Plan denied your request. The Plan says the enrollee's needs are custodial.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee presented to the acute hospital with a right hip fracture after a fall. She is walking 90 feet with a rolling walker with contact guard to minimum assistance and is minimum assist for transfers and activities of daily living. She is reported to be medically stable for discharge on outpatient medications. There is no documentation that the enrollee requires skilled nursing services. Although the enrollee does require skilled therapy services, she does not require services on a daily 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 skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Forteo.  You asked the Plan to pre-approve Forteo. The Plan denied your request. The Plan says Forteo to be administered at home is not covered under the Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo.     Benefits for Forteo 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not tried and failed 4 weeks of conservative treatment.

The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain due to lumbar spinal stenosis with neurogenic claudication. In this case, there is no documentation that the enrollee has tried and failed 4 weeks of conservative treatment. The enrollee has not tried and failed 4 weeks of non-surgical or non-injection care, which includes appropriate oral medication(s) and physical therapy to the extent tolerated. The enrollee does not meet criteria for further injections without having concomitant conservative measures. The review has determined that the requested lumbar epidural steroid injection is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the testosterone.

You asked the Plan to pre-approve the testosterone. You say that you would like reconsideration because this drug will be given at the physician's office. The Plan denied your request. The Plan says this 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 the testosterone.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total hip arthroplasty (27130).

You asked the Plan to pre-approve the total hip arthroplasty (27130). You say that the member has been experiencing extreme discomfort that continues to inhibit him from performing daily activities. The Plan denied your request. The Plan says the criteria for coverage has not been met.

The Plan must follow Medicare rules. Medicare rules say that a total joint arthroplasty is considered reasonable and necessary for individuals who meet one or more of the criteria.

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 total hip arthroplasty (27130). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Our reviewer says that there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the member does not meet the LCD coverage criteria for total hip arthroplasty. 

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 total hip arthroplasty (27130) have not been met. Therefore, we decided that the Plan does not have to pre-approve the total hip arthroplasty (27130).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the toilet chair with bilateral handle bars.

You asked the Plan to pre-approve the toilet chair with bilateral handle bars. You say that you would like reconsideration because your condition makes using a regular toilet difficult. The Plan denied your request. The Plan says the requested item is not considered medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the toilet chair with bilateral handle bars.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of breast implants (19328).

You asked the Plan to pre-approve the removal of breast implants (19328). You say that the implants have caused pain and having implants removed is not as involved as reconstruction. You say that the removal of the implants should be approved. The Plan denied your request. The Plan says as the initial implantation was for cosmetic purposes, the request for removal is considered cosmetic in nature, and therefore 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 the removal of breast implants (19328). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record as provided indicates that the requested procedure is cosmetic in nature and results from complications of a cosmetic procedure. The records provided do not establish the medical necessity and reasonableness, as defined by Medicare rules, and the requested service is not 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 the removal of breast implants (19328) have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of breast implants (19328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the goniotomy (65820) in the left eye.  You asked the Plan to pre-approve the goniotomy. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says there is no documentation of previous laser trabeculectomy.  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 goniotomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been documented that maximum tolerated medical therapy and laser trabeculoplasty have not achieved target intraocular pressure.  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 goniotomy have not been met. Therefore, we decided that the Plan does not have to pre-approve the goniotomy (65820) in the left eye.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is 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 ventilators may be covered when they are 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 home ventilator. Our reviewer says you presented to the hospital with COPD exacerbation requiring steroids, antibiotics, bronchodilators, and oxygen with BiPAP with improvement. On discharge, a home mechanical ventilator set in TTV-VAPS mode was requested. Based on the provided ventilator requirements there was no report that would suggest that these settings could not be delivered by a BiPAP to justify this request. Therefore, a portable mechanical ventilator does not meet Medicare coverage 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 a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 a review of the applicable guidelines does not support the use of this device for long term relief of back and leg pain.

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 this device is experimental. More research is needed. 

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 the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 18 and 20, and a pontic (D6240) for tooth # 19.  You asked the Plan to pre-approve a fixed bridge. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested three-unit posterior fixed bridge is beyond the scope of benefit coverage.  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. The Plan covers a fixed bridge when the services are medically necessary and reasonable.   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 fixed bridge. Our reviewer says that the requested fixed bridge does not meet the criteria for coverage. Our physician reviewer found the provided documentation indicates multiple missing posterior mandibular teeth # 19, 29, 30 and 31. The reviewer found that the Plan covers fixed bridges only in the anterior region if no posterior teeth are missing. Therefore, the reviewer found that the requested fixed bridge for teeth # 18, 19, and 20, does not meet the criteria for coverage.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a fixed bridge have not been met. Specifically, the file shows that fixed bridges are not covered when there are other missing posterior (back) teeth. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 18 and 20, and a pontic (D6240) for tooth # 19.