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

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Keytruda. Our reviewer says that the medication is necessary. Our physician reviewer found this enrollee has been on pembrolizumab for recurrent disease since 2018. Recent scans with question of compression in 2 areas. If progression on a PD-1 axis inhibitor after initial response is limited to one or two sites ("oligoprogression"), local therapy to the site(s) of progression (ie, radiation, thermal ablation, or surgery) with continuation of systemic therapy with the PD-1 axis inhibitor may represent an alternative to salvage systemic therapy. Therefore, the continued use of pembrolizumab for this enrollee is reasonable 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
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 use of Keytruda (pembrolizumab).
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not cisplatin eligible, and this drug is recommended because of the poor response to chemotherapy with squamous cell cancer. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the documentation does not include the necessary tumor marker testing of PD-L1 of 10% or greater.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the enrollee does not meet the criteria for the requested use of Keytruda. Our physician reviewer found the requested use of Keytruda is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Keytruda is FDA-approved for the treatment of Bladder cancer, Bacillus Calmette-Guerin (BCG)-unresponsive, high-risk, non-muscle invasive with carcinoma in situ, with or without papillary tumors in
patients ineligible for or have elected not to undergo cystectomy. The enrollee in this case does not have non-muscle invasive with carcinoma in situ. This requested use of Keytruda is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda (pembrolizumab).
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 these services are medically necessary. The Plan denied your request. The Plan says that you are unlikely to tolerate 3 hours of intensive therapy daily with at least 15 hours of intensive rehabilitation within a 7 consecutive day period based on the documentation from treating therapists.
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.
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 altered mental status and possible subacute stroke. Your 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. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee does not
meet the medical guideline coverage for Durolane.
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 Durolane. Our reviewer says that
Durolane (J7318) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the
enrollee has not tried and failed the required drug, Hyalgan, Hymovis, and Synvisc. Our reviewer also found
that there is no indication that the Plan's required drugs 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 Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane (J7318).
Appeal type: Transportation
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare pays only for ambulance transport. Ambulance vehicles must be designed and equipped to meet certain requirements. The vehicle must have emergency warning lights, sirens, communications equipment, a stretcher, linens, emergency medical supplies, oxygen equipment and other life-saving equipment. The vehicle also must be staffed with two people, one of whom is certified as an emergency medical technician. Medicare will not pay for transport by vehicles that do not meet these requirements. You can find this rule at 42 CFR Section 410.41(a). The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The transport offered must be used only for the enrollee's health care needs, such as transport to the doctor's office. The transport must be arranged or directly provided by the health plan. The transport may not be used for other than health-related purposes. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 4, Section 30.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers routine, non-ambulance transportation as a supplemental (extra) benefit. This benefit covers up to 36 one-way ground transportation trips per calendar year. Trips must be to or from plan-approved locations and each one-way trip must not exceed 50 miles of driving distance. A trip is one-way transportation; a round trip is two trips. Trips are curb-to-curb service. You can find this information on pages 4-72 to 4-73 of the Plan's 2021 Evidence of Coverage (EOC).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility or continuation of therapies at home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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. The enrollee was admitted for a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to provide additional payment for the Skilled Nursing Facility (SNF) services provided on July 10, 2019, through July 31, 2019.
You asked the Plan to provide additional payment for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the provider failed to send the required assessments so the standard rate was applied.
The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have been met. Specifically, the record clearly includes the required assessments. The record also indicates that these assessments were completed within the appropriate timeframe. It is the burden of the Health Plan to substantiate the denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to provide additional payment for the Skilled Nursing Facility (SNF) services provided on July 10, 2019, through July 31, 2019.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
You asked the Plan to pre-approve the additional skilled nursing visit. The Plan denied your request. The Plan says the notes show that your condition is stable, and your wound is almost healed.
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 the additional skilled nursing visit. Our reviewer says that the additional skilled nursing visits are not medically reasonable and necessary. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration for the six denied home health skilled nursing visits. Our reviewer found that provided records do not document why the already approved home health skilled nursing visits are inadequate to treat your condition. Our physician reviewer also found that the health plan has stated that additional home health nursing services will be considered if they are requested and additional supporting medical records are received. 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 additional skilled nursing visit have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are subject to the criteria listed
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 facet joint injections. Our reviewer says
that the requested service is not medically reasonable and necessary. Our physician reviewer found that the
enrollee has a history of low back pain with radiculopathy due to lumbar spondylosis. The enrollee has had an
increase in lower back and right hip pain. In this case, the enrollee has low back pain with associated
radiculopathy. The review has determined that the medical records provided do not meet the requirements
listed in the LCD for Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections. have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this request is medically
necessary. The Plan denied your request. The Plan says this procedure is only allowed twice a year.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two
(2) radiofrequency sessions will be reimbursed per rolling 12 months
We looked at the file and Medicare rules. In this case, the benefit limit for radiofrequency ablation services
have been exhausted. Based on this information, we decided that Medicare rules for coverage of
radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to preapprove
radiofrequency ablation services.
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 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 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 you do not require skilled nursing and/or 
skilled therapy services on a daily basis. Although further rehabilitation services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide or stair lift for the enrollee.
You asked the Plan to pre-approve a stair glide or stair lift. You say that a stair life is medically necessary for the enrollee to use the stairs in his home. The Plan denied your request. The Plan says this equipment is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide or stair lift for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Viibryd.
You asked the Plan to pre-approve Viibryd. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Viibryd.
Benefits for Viibryd 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).
You asked the Plan to pre-approve a knee orthosis. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that the requested orthosis is subject to the criteria listed 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 a knee orthosis. Our reviewer says that the requested device is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria for the requested knee orthosis (L1843) as defined by the Local Coverage Determination (LCD): Knee Orthoses (L33318). Provided records do not document knee instability by examination and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1843).