Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skin graft (NovaFix) (CPT code Q4254) for the
enrollee.
You asked the Plan to pre-approve the skin graft (NovaFix). You say that the enrollee has a diabetic foot
wound ulceration since September 1, 2021. You the ulcer is not infected and has a granular base with adequate
blood flow to heal the ulcer. You state it is medically necessary to treat the chronic ulcer/wound with advance
therapy such as skin substitute, since the enrollee has not shown signs of improvement over the past four (4)
weeks despite attempts of conservative treatment. The Plan denied your request. The Plan says your request is
not medically necessary because the enrollee's records do not show the enrollee has tried and failed at least
thirty (30) days of standard wound therapies.
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 skin graft (NovaFix). Our physician
reviewer found the enrollee has a chronic diabetic ulcer since September 1, 2021, that has not improved with
four (4) weeks of conservative treatments (bandage, debridement). The ulcer is not infected and has a granular
base with adequate blood flow to heal the ulcer according to the records. NovaFix skin graft was requested. On
October 7, 2021, the wound measured 9.1 x 6.2 x 0.5 cm. There was no prior measurement provided to help
show failure of conservative treatments. Therefore, this request for NovaFix does not meet LCD criteria for
Medicare.
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 skin graft (NovaFix) have not been met. Therefore, we decided that the Plan
does not have to pre-approve the skin graft (NovaFix) (CPT code Q4254) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding motorized scooter.
You asked the Plan to pre-approve a folding motorized scooter. You say that you do not have a reliable battery for your current scooter. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 power wheelchair. Your current Quickie Pulse 6 power wheelchair serves the same purpose as a folding motorized scooter. The documentation shows that your current power wheelchair is in good working condition. Therefore, we decided that the Plan does not have to pre-approve a folding motorized scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The Plan denied your request. The Plan says the requested Aranesp is 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 Aranesp. Our reviewer says that the requested Aranesp is not medically necessary. Our physician reviewer found the enrollee has evidence of iron deficiency anemia and would need to be repleted prior to Aranesp. The service is not reasonable or medically necessary or likely to be safe and effective. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
You asked the Plan to pre-approve a seat lift chair and mechanism. You say that The Plan denied your request. The Plan says Medicare does not cover the chair often sold with this mechanism. The Plan states you do not meet the medical criteria required for approval of the seat lift mechanism.
The Plan must follow Medicare rules. The rules says that the upholstered chair often sold with a seat lift mechanism is not covered by Medicare. The rules say that a seat lift mechanism alone is covered if all the conditions listed are met. Based on the records provided you do not meet all the conditions required to approve a seat lift mechanism. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and mechanism
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health occupational therapy (OT) visits.
You asked the Plan to pre-approve 3 home health OT visits. 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 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 3 home health OT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 home health OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health occupational therapy (OT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit system.
You asked the Plan to pre-approve a transit system. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a transit system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the K0108 transit system exceeds your medical need and is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The requested item is for outdoor use and not required for you to perform mobility related activities of daily living (MRADLs) in the 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 a transit system have not been met. Therefore, we decided that the Plan does not have to pre-approve a transit system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special adaptive steering device components (K0108).
You asked the Plan to pre-approve special adaptive steering device components. You say that this is medically necessary. The Plan denied your request. The Plan says these components are included in the base item.
The Plan must follow Medicare rules. Medicare rules say that code K0108 is appropriately used at the time of initial issue only when the drive control interface that is provided is not included in the base code and there is no specific E code which describes it. We looked at the file and Medicare rules. The requested items are included in the base code, which has been approved. Based on this information, we decided that Medicare rules for coverage of special adaptive steering device components have not been met. Therefore, we decided that the Plan does not have to pre-approve special adaptive steering device components (K0108).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on February 18, 2021, through March 19, 2021.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member did not have any daily skilled needs.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of February 18, 2021. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. 
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on February 18, 2021, through March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre. You say that this device helps you a lot with your diabetes. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you are requesting additional transportation trips for testing and therapy needing to be done from different facilities. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 48 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient ophthalmology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have been a patient of this provider for over 30 years. You trust and feel comfortable with them in dealing with your glaucoma. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient ophthalmology office 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 an acute inpatient hospital stay.
You asked the Plan to pre-approve acute inpatient hospital stay. You say that this service is medically necessary. The Plan denied your request. The Plan says the associated procedure, total shoulder arthroplasty, is approved as an outpatient procedure. The Plan also says that the requested inpatient stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital stay. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The reviewer found that the documentation does not indicate that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Therefore, the requested acute inpatient hospital stay is 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 acute inpatient hospital stay have not been met. Specifically, the file does not show that the enrollee's hospital care is expected to span two midnights. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital stay
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMems.
You asked the Plan to pre-approve CardioMems. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 CardioMems. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record provided does not indicate the enrollee's post treatment degree of heart failure. The elements of the coverage criteria are not satisfied. 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 CardioMems have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMems.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fulvestrant.
You asked the Plan to pre-approve Fulvestrant. You say that the medication is 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 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 Fulvestrant. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the combination of fulvestrant and alpelisib is not FDA approved for the treatment of leiomyosarcoma. Use is not supported by the NCCN guidelines, major drug compendia, or the medical literature. The service is 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 Fulvestrant have not been met. Therefore, we decided that the Plan does not have to pre-approve Fulvestrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (D3330) provided by a participating provider.
You asked the Plan to pre-approve endodontic therapy. You say that you would like approval for these dental services. The Plan denied your request. The Plan says the dental service being requested is not a covered benefit.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (D3330) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the requested system. The Plan denied your request. The Plan says the item is non-covered by Medicare.
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. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an orthopedic office visit. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-network.
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 orthopedic office visit to be provided by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee was on alendronate and showed progression of her condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not being requested for a medically-accepted indication.
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 Prolia. Our reviewer says that the enrollee does not meet the criteria for Prolia. Our physician reviewer found the requested use of Prolia is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia