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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs assistance with her recovery. The
Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 care. Our reviewer says that daily
skilled services are not necessary. 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 skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexamethasone tablets for the enrollee.
You asked the Plan to pre-approve the tablets. You say that this is medically necessary. The Plan denied your
request. The Plan says this is self-administered and covered by the pharmacy benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone tablets for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology visit to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve specialist visit. You say that you are comfortable with this doctor and they
already know your history and situation. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be
treated by an in-network specialist.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an ophthalmology visit to be provided by an out-of-network (OON) provider.
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 you would like reconsideration because the requested LTACH services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested LTACH services.
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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 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 Qutenza.
You asked the Plan to pre-approve Qutenza. You say that Qutenza is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of Qutenza.
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 Qutenza. Our reviewer says that
Qutenza is not medically necessary. Our physician reviewer found the Food and Drug Administration has not
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have
to pre-approve Qutenza.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The
Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
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
requested Keytruda is not medically necessary. Our physician reviewer found the record indicates that the
enrollee has a diagnosis of EGFR mutated stage IV non-small cell lung cancer. The record indicates that the
requested drug is being administered as part of a second line chemotherapeutic regimen including Carboplatin,
pemetrexed and pembrolizumab. 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. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
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 you would like reconsideration because the requested LTACH services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested LTACH care.
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 record indicates that the enrollee is improving but still requires oxygen supplementation and other acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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 admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, such as a skilled nursing facility (SNF).
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested IRF 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity gangrene and sepsis and had an above the knee amputation. Medical problems are stable. There are 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. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Bimatoprost injection.
You asked the Plan to pre-approve a Bimatoprost injection. You say that the injection is medically necessary.
The Plan denied your request. The Plan says that the member has had medication that has proven to be
effective at lowering the pressure in their eyes.
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 a Bimatoprost injection. Our reviewer
says that a Bimatoprost injection is medically necessary in this case. Our physician reviewer found that the
Food and Drug Administration (FDA) has stated that the requested service is indicated to reduce elevated
intraocular pressure in patients with open angle glaucoma or ocular hypertension. The enrollee has a covered
diagnosis. The FDA has stated that the requested drug is indicated for the enrollee's condition.
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 Bimatoprost injection have been met. Therefore, we decided that the Plan has
to pre-approve a Bimatoprost injection.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy.
You asked the Plan to pre-approve the wireless capsule endoscopy. You say that you would like reconsideration because the requested endoscopy is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested endoscopy.
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 wireless capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested service is not indicated for use for follow-up of persons with known small bowel disease other than Crohn's disease. the record indicates that the enrollee has iron deficiency anemia.
The record indicates that the enrollee has duodenal arteriovenous malformations and numerus jejunal angioectasias. The requested test is being used for follow-up of known small bowel disease other than Crohn's disease. 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 wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve wireless capsule endoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve Coolief cooled radiofrequency ablation
(RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has right knee pain due to
unilateral primary osteoarthritis. She reports an average pain level of seven out of 10. She had a right knee
diagnostic nerve block with 90 percent pain relief. The requested genicular nerve RFA is considered
investigational in nature and therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve Coolief cooled radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178).
You asked the Plan to pre-approve Eylea. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, bevacizumab.
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 Eylea. Our reviewer says that the step
therapy criteria for Eylea has not been met. Our physician reviewer found the provided documentation does not
indicate that the enrollee has tried and failed the required drug, bevacizumab. The reviewer also found that
there is no indication that the plan's required drug would likely be less effective and/or likely 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 Eylea have not been met. Specifically, the file does not indicate that the enrollee
has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Eylea
(J0178).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of bilateral globus pallidus interna (GPi)
deep brain stimulation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that deep brain stimulation is only covered for
diagnosis of essential tremor or Parkison's disease.
Spasmodic torticollis is not a covered diagnosis for this request. 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 placement of bilateral globus pallidus interna (GPi) deep brain stimulation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy.
You asked the Plan to pre-approve endovenous ablation therapy. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the member does meet Medicare criteria for coverage.
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 endovenous ablation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication that conservative therapy has been attempted. The CEAP classification is not indicated, and there are no physical examination findings noted. There are no ulcerations or episodes of hemorrhage. There is no indication that the varicosities interfere with activities of daily living. The review has determined that the enrollee does not meet the coverage indications for endovenous ablation therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approved the Urolift procedure.
You asked the Plan to pre-approved the Urolift procedure. The Plan denied your request. The Plan says this 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-approved the Urolift procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that Urolift is not indicated for enrollees with prostate cancer. In addition, the records
do not indicate that the prostate size is less than 100cc in size.
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 Urolift procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approved the Urolift procedure.