Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that you feel the Plan should reconsider their original admission denial and grant authorization for the enrollee to be admitted in order to give her the best opportunity for continued improvement and recovery from ongoing acute medical conditions. The Plan denied your request. The Plan says there is no documentation that the enrollee will benefit from and improve with LTACH management given neurological status and chronic vent-dependence.  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. Our reviewer found that 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. Our physician reviewer also found that 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit (Q5106).  You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says this drug is not being prescribed for a medically accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and Drug Administration (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 Retacrit (Q5106) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the review has determined that the requested use of Retacrit (Q5106) is not FDA-approved for the enrollee's diagnosis. Our reviewer also found that its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 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 Retacrit (Q5106).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Venelex ointment (J3490).  You asked the Plan to pre-approve Venelex ointment. You say that this is the only medication that works for your medical problem. You also say that you have been using it for some time and this medication has been covered under Part B for many months. The Plan denied your request. The Plan says the requested drug is not of a type and/or used for a condition that is covered under the medical 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 Venelex ointment (J3490).   Benefits for Venelex ointment 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OsteoAmp Allograft and bone marrow aspirate 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 a standard allograft product might be covered.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found osteoamp allograft remains experimental in cases of spinal surgery. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve OsteoAmp Allograft and bone marrow aspirate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an intracept procedure.  You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.  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 service is not considered medically reasonable and necessary in this case. Our physician reviewer found there is minimal support in the clinical evidence for using the Intracept device for chronic low back pain thought to be of vertebrogenic origin. Studies did not consistently or predominantly report clear benefits or advantages in patient-oriented outcomes compared with a comparison group and were of generally poor or fair quality.      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. Specifically, there is not enough evidence indicating safety and efficacy of this service for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opdivo, Yervoy, Paraplatin, Taxol, Zofran, and Decadron.  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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has non-small cell lung cancer (NSCLC) and is on Imfinzi after carbo/taxol then pemetrexed. The requested combination of Yervoy/Opdivo is for first line therapy. The enrollee has progressed on several prior lines of therapy. The requested Opdivo, Yervoy, Paraplatin, Taxol, Zofran, and Decadron are not safe and effective and 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 Opdivo, Yervoy, Paraplatin, Taxol, Zofran, and Decadron.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prednisolone.  You asked the Plan to pre-approve Prednisolone. The Plan denied your request. The Plan says Prednisolone is a self-administered drug and does not fall under Part B coverage.  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 Prednisolone.   Benefits for Prednisolone 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: 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 has been in the current facility for over a month and needs to be transferred to a long-term facility. The Plan denied your request. The Plan says criteria for admission to the LTACH have 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 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. Our reviewer found that 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. Our physician reviewer also found that 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Methotrexate tablets.  You asked the Plan to pre-approve the Methotrexate tablets. You say that the drug is medically necessary. The Plan denied your request. The Plan says the requested drug is an oral, self-administered drug and is not covered under the medical 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 the Methotrexate tablets.   Benefits for the Methotrexate tablets 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two registered nurse (RN) visits, eight licensed vocational nurse (LVN) visits, and 10 physical therapy (PT) visits.  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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 records do not support that you need skilled nursing or skilled therapy services to provide medically necessary treatment. You do not require skilled nursing or skilled therapy services to effectively provide treatment, care, and/or services to improve your condition, perform a maintenance program, or maintain your condition or prevent deterioration. You have been medically stable with no recent worsening of chronic medical problems or hospitalizations. The home health 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve two registered nurse (RN) visits, eight licensed vocational nurse (LVN) visits, and 10 physical therapy (PT) visits.
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 IRF care to regain strength and mobility to be able to safely return home. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 that that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a leadless pacemaker (33274).  You asked the Plan to pre-approve a leadless pacemaker (33274). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. In this case, Medicare guidelines say leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. The file does not show that the enrollee is to have the procedure performed under a CMS approved CED study. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker (33274) have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker (33274).
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 if the enrollee goes to a lower level of rehabilitation, it will compromise the enrollee achieving the highest level of maximum function necessary to resume highest quality life with reintegration into the community. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the OneTouch Ultra test strips.  You asked the Plan to pre-approve the OneTouch Ultra test strips. You say that the items are medically necessary. The Plan denied your request. The Plan says the requested item is not the preferred brand.  The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OneTouch Ultra test strips have not been met. Specifically, no medical records were submitted to indicate the requested item is medically necessary over the preferred brand. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Ultra test strips.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total knee arthroplasty 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 there is no documentation of significant joint destruction and cartilage loss.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding imaging evidence of moderate to severe osteoarthritis in the right knee. Positive findings are strongly suggestive of a highly symptomatic medial meniscal tear. Additionally, trial and failure of all available conservative treatments is not clearly documented. There is notation of failure of a cortisone injection; however, it is not clear when this injection was provided and if the injection had provided any significant benefit. Detailed documentation is not evident regarding any trial and failure of any viscosupplementation injections for the right knee prior to consideration for the surgery.    There is limited published, large-scale, long-term peer-reviewed literature that shows total knee arthroplasty to be an effective and/or safe treatment without documentation of moderate to severe osteoarthritis in the knee that has failed all available conservative care treatments. 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 request for 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.  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 lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are 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 a Vertiflex Superion spacer.