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

We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289), for the enrollee.

You asked the Plan to pre-approve the CardioMEMS device. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been hospitalized for heart failure in the past year. In a note, the physician indicates that the enrollee has NYHA class II heart failure. The elements of the coverage determination 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says the rules for a therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

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 therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wedge pillow.
You asked the Plan to pre-approve a wedge pillow. You say that this is necessary due to the water gain on your legs and body. The Plan denied your request. The Plan says this is not a covered service.
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 wedge pillow.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epoetin alfa (J0885).

You asked the Plan to pre-approve epoetin alfa. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 epoetin alfa. Our reviewer says that the requested epoetin alfa treatment is not medically necessary. Our physician reviewer found the records show that the enrollee has stage IV prostate cancer, was receiving Xtandi, and is now being started on Zytiga. The enrollee is not receiving myelosuppressive chemotherapy. The record indicates the enrollee has a creatinine of 0.67 with a normal predicted glomerular filtration rate. The use of epoetin alfa in this circumstance is not supported. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epoetin alfa have not been met. Therefore, we decided that the Plan does not have to pre-approve epoetin alfa (J0885).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM (CPT code K0553), for the enrollee.

You asked the Plan to pre-approve the CGM. You say that the monitor is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve CGM (CPT code K0553), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says treatment can happen in a lower level of care, such as outpatient treatment.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment facility as you could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation. There were no auditory or visual hallucinations or delusions. You were not any behaviors or aggression, being cooperative and compliant, while not showing any acute threats to safety. The health plan's denial of continued inpatient psychiatric services appears appropriate.

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prothrombin, coagulation factor II (eg, hereditary hypercoagulability) gene analysis (CPT code 81240) and coagulation factor V (eg, hereditary hypercoagulability) gene analysis (CPT Code 81241), for the enrollee.

You asked the Plan to pre-approve the services. You say that the testing for inherited thrombotic disorders can lead to the discovery of risk factors. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee is not pregnant and has no signs or symptoms of the disease.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found there is no current symptoms or signs of thrombosis or thromboembolism was noted for this enrollee and no report of this enrollee having a history of the same as required by the Medicare criteria. Therefore, criteria for this testing 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve prothrombin, coagulation factor II (eg, hereditary hypercoagulability) gene analysis (CPT code 81240) and coagulation factor V (eg, hereditary hypercoagulability) gene analysis (CPT Code 81241), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion of an inflatable penile prosthesis.

You asked the Plan to pre-approve surgical service. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee has not had a failure of conservative therapies or testosterone levels that are low and unresponsive to medication.

The Plan follows Medicare rules. Medicare rules say that coverage may be provided for treatment of sexual impotence when medically appropriate.

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 surgical service. Our reviewer says that the enrollee meets the Medicare criteria for the requested procedure. Our physician reviewer found the records indicate that the enrollee has failed at least 2 phosphodiesterase type 5 inhibitors and has no erectile function. The enrollee has significant diabetes and hypertension. The provided record is sufficient to establish the appropriateness of the requested service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical service have been met. Therefore, we decided that the Plan has to pre-approve insertion of an inflatable penile prosthesis.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve raised toilet seat, and shower chair (CPT code E1399 x2), for the enrollee.

You asked the Plan to pre-approve the items. You say that the enrollee needs the items due to the hip replacement that is getting done. The Plan denied your request. The Plan says bathtub seats and toilet seats are considered hygienic equipment and are not medical in nature.

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 raised toilet seat, and shower chair (CPT code E1399 x2), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex procedure.

You asked the Plan to pre-approve the Coflex procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the service or procedure is helpful for treatment of your health problem.

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 Coflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show safety and efficacy of the device. There is no spinal instability. Hardware is not needed in this case. 

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 Coflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex procedure.
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 stay is not medically necessary.

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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The clinical assessment in the case file does not support that there are services at the LTACH from which the enrollee is reasonably expected to benefit and improve. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary, and the enrollee would benefit from this surgery. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator (E0466). You say that the requested home ventilator (E0466) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator (E0466).
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 home ventilator (E0466). Our reviewer says that the enrollee does not meet criteria for the requested home ventilator (E0466). Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD). However, there is no documentation of CO2 retention when in a stable state. The ventilator is ordered in the AVAPS mode, which can be provided by certain BiPAP devices, and Medicare does not cover a home ventilator when used as BiPAP. There is no evidence that BiPAP has been tried and failed. The enrollee does not have neuromuscular disease or thoracic restrictive disease. 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 home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to adjust the charges for these dental services. We decided that the Plan does not have to waive the total cost for these services
You asked the Plan to adjust the charges for these dental services. You say that you were not aware what you were agreeing to when you signed this treatment plan. You do not feel that you should have to pay more than what the Plan would pay for these services. The Plan says that it was decided that the provider must credit your account in the amount of $626 for the amount you overpaid for the services rendered. The remaining amount paid can be refunded if you inform the provider you do not wish to proceed with the treatment plan.
We decided that the Plan has to adjust the charges for these dental services.
The Plan follows Medicare rules. Medicare rules say that dental services are not covered. However, the Plan does cover certain dental services at the cost sharing rates listed in the Medicare rules section. In this case, the file shows that you were charged and paid via CareCredit in the amount of $2740 for the fixed bridgework provided. However, you cannot be asked to pay more than $1665 for these services. This is calculated with two $50 copayments for the core buildups, $425 for the crown on tooth #11, and since teeth 12, 13 are considered molars, you pay $425 for each plus a $150 upcharge for porcelain. The Plan indicated that asked the provider to credit your account by $626; but it is not clear how this number was calculated. The information reviewed shows that you were overcharged in the amount of $1075, which is the amount that must be credited. Therefore, we decided that the Plan has to adjust the charges for these dental services.
We also decided that the Plan does not have to waive the total cost for these services.
As noted above, the contract indicates that enrollees must pay $1665 in cost sharing for the services you received. This is the correct amount based on your contract and cannot be waived or adjusted. Therefore, we decided that the Plan does not have to waive the total cost for these services.
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: Inpatient Hospital
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 the intensity of services
provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services
and regular physician evaluation. Your care needs can be met 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 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the enrollee has not tried and failed Xeomin.
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 Botox. Our physician reviewer found that the enrollee has spastic hemiplegia, affecting the non-dominant left upper and lower extremity, due to a stroke. The Plan requires a trial of Xeomin before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or likely have adverse effects for this 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.