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

 We decided that the Plan does not have to pay for the paramedic intercept services (S0207) provided on June 12, 2021.  You asked the Plan to pay for paramedic intercept. You say that these services were necessary, and the Plan paid for the ambulance services provided by one company. You feel these services should also be covered by the Plan. The Plan denied your request. The Plan says paramedic intercept services are not separately payable under Medicare coverage rules.  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services (S0207) provided on June 12, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.
You asked the Plan to pre-approve the drug. You say that this is medically necessary for treatment of rheumatoid arthritis. The Plan denied your request. The Plan says a step therapy exception cannot be granted. 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Remicade, infliximab, Inflectra, or Simponi Aria before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided that would indicate that these preferred drugs would likely be less effective and/or likely to 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolate caplet 250mg
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this request falls under Part D.
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 Mycophenolate caplet 250mg.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member cannot do activities of daily living.
The Plan denied your request. The Plan says that the enrollee does not have skilled nursing or therapy needs
that need to be provided on a daily basis as an inpatient only status.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for an anterior cervical discectomy and fusion at C6-7 and Orthofix Construx Mini Spacer and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is approved for an anterior cervical discectomy and fusion at C6-7 and Orthofix Construx Mini Spacer. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requirements are not met for this drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab as
single agent therapy is not approved for squamous cell carcinoma of any type. The enrollee has not had prior
therapy ad has not had testing to indicate benefit of immunotherapy. Its use is not Food and Drug
Administration (FDA) approved or supported by the major drug compendia or the medical literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio for the enrollee.
You asked the Plan to pre-approve Zarxio. You say that the patient has an increased risk for infections due to
recently treated for pneumonia while on chemotherapy. The Plan denied your request. The Plan says that this is
not supported for the enrollee.
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 Zarxio. Our reviewer says that Zarxio is
not medically reasonable and necessary for the enrollee. Zarxio is not FDA-approved for the enrollee's
diagnosis. The use supported of Zarxio 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. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of Zarxio.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to
pre-approve Zarxio for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mitral valve valvuloplasty with cardiopulmonary bypass.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that with the MRI showing mild to moderate mitral regurgitation, the mitral valve surgery is not indicated.
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 requested services are not considered medically reasonable and necessary in this case. The documentation in the case file is conflicting in regard to the severity of your mitral valve regurgitation. While a symptomatic patient with chronic severe primary mitral valve regurgitation would be a candidate for corrective mitral valve surgery, the MRI contradicts the diagnosis of severe mitral valve regurgitation. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve mitral valve valvuloplasty with cardiopulmonary bypass.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a 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 enrollee is receiving appropriate in-patient acute care and does not
require transfer to a Long-Term Acute Care Hospital (LTACH).
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 LTACH for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve a continuation of SNF care. You say that the enrollee had pneumonia and went to the hospital where blood clots were found. You say that the enrollee is very weak and cannot walk unassisted. You say that when the enrollee stands she drifts backwards. You say that the enrollee's ability to regain maximum function would be impaired if she were released now. The Plan denied your request. The Plan
says the enrollee does not meet the requirements for approval. The Plan says that the enrollee's medical issues
appear essentially stabilized.
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 a continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not
have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The
enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal
supervision. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical
matter, can be provided at a lower level of 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 a continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
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 the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records do not show they have failed several attempts to remove the enrollee from a breathing machine (ventilator) and do not show the enrollee is expected to require more than twenty-five (25) days of continued hospital care. The Plan states the enrollee is recovering from an acute illness. The Plan states they will need continued care, including attempts to get off the breathing machine and therapy to get stronger. The Plan states the enrollee can safely receive this care in another setting, such as in their current acute care facility, a skilled nursing facility (SNF) or at home with home health services or outpatient setting if appropriate.
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 was admitted with acute on chronic respiratory failure due to recurrent pneumonia. The record indicates that the enrollee has muscular dystrophy and is ventilator dependent. The record indicates that the enrollee has worsening abdominal pain and requires ongoing acute care services, including surgical evaluation.
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 they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there are no stated contraindications to the preferred products.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed Skyrizi. There is no indication that Skyrizi would likely be less effective and/or 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization services.
You asked the Plan to pre-approve the requested services. You say that the catheter placement is necessary to treat the enlarged prostate. The Plan denied your request. The Plan says this is not the standard of medical care.
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 requested services. Our physician reviewer found that the enrollee has a two-year history of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The BPH is not being treated with any medication. The enrollee's American Urological Association (AUA) symptom score is 11. His prostate size is 49 cc by scan. Prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic BPH. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization services
Appeal type: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on March 25, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered because you were not in the hospital, and it wasn't an office visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Physician/Practitioner Services, Including Doctor's Office Visits.
You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the hospital may ask for a separate cost share for certain hospital medical services and you were seen by a specialist in the emergency department. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit (99214) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says the request for a home mechanical ventilator set in Intelligent Volume Assured
Pressure Support (iVAPS) mode that could be delivered by bilateral positive airway pressure (BiPAP is not
covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our reviewer says that
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have
diagnosis of chronic obstructive pulmonary disease, although the record does not include pulmonary function
tests. During a recent admission for an exacerbation, you had evidence of chronic hypercarbic respiratory
failure, with a partial pressure of carbon dioxide (PaC02) of 65. You may get benefit from support with
bilateral positive airway pressure (BiPAP) at night, but Medicare does not cover a home ventilator when used
as BiPAP. Certain BiPAP devices can provide the AVAPS mode that has been ordered.
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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a portable ventilator.