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

We decided that the Plan does not have to pre-approve a CTA scan of the chest (71275).
You asked the Plan to pre-approve a CTA scan of the chest. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service has not been documented to be medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA scan of the chest have not been met. Specifically, no medical records were provided to support the medical necessity of the requested service. Therefore, we decided that the Plan does not have to pre-approve a CTA scan of the chest (71275).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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 grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve OON services. You say that you have routine appointments and want to
continue care. The Plan denied your request. The Plan says care can be safely transferred to an in-network
provider.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve an
office visit to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary and reasonable for the enrollee. The Plan denied your request. The Plan says the rules for LTACH care 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 there is no documentation provided necessitating admission to an 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ROMTech Portable Connect Adaptive Rehab Device and ROMTech AccuAngle Bluetooth system.
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 records show that you have a history of osteoarthritis and need the requested device for after knee surgery. The requested ROMTech Portable Connect Adaptive Rehab Device and ROMTech AccuAngle Bluetooth system is not medically necessary, as it is not proven effective nor the standard of care after knee surgery and the bluetooth system exceeds your medical need. 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 ROMTech Portable Connect Adaptive Rehab Device and ROMTech AccuAngle Bluetooth system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair self-leveling cup holder.

You asked the Plan to pre-approve a self-leveling cup holder (K0108). You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says an accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair self-leveling cup holder.
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 records provided support the need for care in an LTACH. You say that this is the safest discharge plan, and it allows for the highest potential level of recovery. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an 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 necessitating 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant provided on March 10, 2021.
You asked the Plan to pay for the endosteal implant. You say that you experienced a traumatic fall which resulted in fracture of tooth #9. You also say that it has required tooth extraction and implant surgeries. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.
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 pay for the surgical placement of implant body: endosteal implant provided on March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on June 13, 2021 with a stroke and resulting right sided weakness. You are walking more than 100 feet and tending to activities of daily living with minimal supervision. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health skilled nursing visits.
You asked the Plan to pre-approve home health care. You say that you are often not taking your medications without a nurse being present and are unable to perform activities of daily living due to your conditions. The Plan denied your request. The Plan says the denial of authorization for additional home health skilled care visits is correct. The Plan also says that they have approved home health care for 3 days a week for 30 days so that a transition can be implemented to meet your needs.
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 home health care. Our reviewer says that you do not meet the Medicare criteria for continued home health visits beyond what the Plan already approved. Our physician reviewer found the records do not show that additional 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 or prevent deterioration. The records do not indicate intravenous medications, new enteral feedings, complex wound care, or other skilled professional nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) and the nail debridement (11721) rendered by the out of network (OON) provider on February 21, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) and the nail debridement (11721) rendered by the out of network (OON) provider on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.

You asked the Plan to pre-approve the system. You say that a new rehab evaluation was completed. The Plan denied your request. The Plan says the power wheelchair is approved, and all accessories are approved except for the power seat elevation feature.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of an implant body (D6010), the provisional implant crown (D6085), and the bone replacement graft (D7953) provided on February 12, 2021.
You asked the Plan to pay for the placement of an implant, the provisional implant crown, and the bone replacement graft. You say that your dentist advised that these services were medically necessary. The Plan denied your request. The Plan says the placement of an implant body is not listed as a covered service. The
Plan says that provisional implant crown is not listed as a covered service. The Plan also says that the bone replacement graft is not listed and therefore is not a covered service either.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the placement of an implant body (D6010), the provisional implant crown (D6085), and the bone replacement graft (D7953) provided on February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for this type of transfer are not 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. At the time of the request, the clinical status is unstable.
The follow up CXR shows worsening infiltrates, concerning for aspiration, and warranting a change in IV
antibiotics. The enrollee remains intermittently confused despite stability of the ICH bleed on imaging. As of
July 5, 2021, the lower extremities were markedly swollen, and there are plans to resume Lasix due to this. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. Medicare criteria for transfer are not met. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve a ventilator. You say that the requested ventilator is medically necessary for
the enrollee due to her diagnosis of COPD. The Plan denied your request. The Plan says Medicare coverage
criteria for the ventilator requested are not met.
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 a ventilator. Our
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records
show the enrollee is an 87-year-old female with COPD with a request for home ventilator to be used for BiPAP
only. The records do not show the enrollee requires full ventilation support which would justify the home
ventilator unit. Medicare coverage criteria are not met. 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 ventilator have not
been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient admission.
You asked the Plan to provide coverage for acute inpatient admission. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 pay for acute inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer states the planned procedure listed under CPT codes 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The records show you are clinically stable. There is no documentation provided to support the expectation that you will require inpatient admission.
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 admission have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AK2 V617F, Exon 12, CALR, MPL, and CSF3R mutation analysis testing.
You asked the Plan to pre-approve the genetic testing. You say that the requested testing is medically necessary
to rule out Plasma Cell Disorder/Monoclonal Gammopathy of undetermined significance. The Plan denied your
request. The Plan says the criteria for coverage 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 the genetic testing. Our reviewer says
that the requested genetic testing is not considered medically reasonable and necessary in this case. Our
physician reviewer found the case file does not contain documentation of BCR-ABL negative test results.
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 genetic testing have not been met. Therefore, we decided that the Plan does
not have to pre-approve AK2 V617F, Exon 12, CALR, MPL, and CSF3R mutation analysis testing.