Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve full night titration study, Polysomnography; initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (95811).
You asked the Plan to pre-approve full night titration study. You say that the enrollee had an HST done and had an RDI of 58. Please see the attached records. The Plan denied your request. The Plan says that the records do not support that the enrollee meets the criteria.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 full night titration study. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found A single PSG is usually sufficient to titrate PAP therapy. Assuming an unattended portable monitoring or auto-titrating PAP device does not provide sufficient data, a single PSG is sufficient to titrate PAP therapy. In contrast to the Health Plan's proprietary criteria, Medicare does not necessarily have a "site of service" requirement for the provision of titration studies. In that regard it can be determined that the member would otherwise meet the requirements of the NCD for the performance of an attended titration study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of full night titration study have been met. Therefore, we decided that the Plan has to pre-approve full night titration study, Polysomnography; initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist (95811).
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is held at an inappropriate
level of care. The Plan denied your request. The Plan says the enrollee has not completed her full course of care
in the hospital.
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 physician
reviewer found that the enrollee has been receiving care in the acute care hospital for bleeding, shortness of
breath, congestive heart failure, and failure to thrive. 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 she 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
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 pre-approve the panoramic x-ray and complete upper and lower 
denture. 
 
You asked the Plan to pre-approve the panoramic x-ray and complete upper and lower denture. You say that it 
is difficult to chew as you can only chew on one side. You say that you cannot eat, and you cracked the upper 
denture. The Plan denied your request. The Plan says the claim was partially approved up to your $1,500 
maximum and the remaining services are not covered as it exceeds the benefit allowance for your plan. 
 
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 Plan is only obligated to pay for 
services up to your $1,500 maximum. Any services requested after the maximum is met will not be covered. 
Therefore, we decided that the Plan does not have to pre-approve the panoramic x-ray and complete upper and 
lower denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 are an 82-year-old male with small bowel obstruction and chronic obstructive pulmonary disease. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT (CPT code 77523), for the enrollee.

You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.

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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy (IMRT)/image-guided radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 

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 PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT (CPT code 77523), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Auricular Stimulator (64555, L8679). 
 
You asked the Plan to pre-approve the Auricular Stimulator. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested stimulator device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the service for auricular peripheral nerve 
stimulation will be denied as non-covered. We looked at the file and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of the Auricular Stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Auricular Stimulator (64555, L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hand specialist visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the hand specialist visit. You say that there are no in-network hand specialists and you need to go out-of-network. The Plan denied your request. The Plan says the provider is out-of-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 the hand specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020), lens sphere (V2300), and progressive lens (V2781) received on April 14, 2021.

You asked the Plan to pay for frames, lens sphere, and progressive lens. You say that you want the Plan to pay for both pairs of eyeglasses. The Plan denied your request. The Plan says the routine eyewear benefit has been exhausted.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames, lens sphere, and progressive lens have not been met. Specifically, the record shows that you had exhausted your eyewear benefit. Additionally, progressive lenses are not a covered benefit. Therefore, we decided that the Plan does not have to pay for frames (V2020), lens sphere (V2300), and progressive lens (V2781) received on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313,
E2377) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed and dress independently supports that the enrollee can control any power options through their own individual switches. 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 additional power wheelchair accessories (E2313, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval to see this out-of-network provider. The Plan denied your request. The Plan says there are in-network tertiary care providers available for these services.
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 specialist services 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 continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have no acute symptoms that require 24-hour inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services beyond August 29, 2021, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place. The services were not reasonably expected to improve your condition or for the purpose of diagnosis.
Based upon review the records, you do not meet the criteria for continued acute inpatient treatment for the dates in question as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations. You were cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee's medical and functional needs are not able to be provided in a lesser setting. The Plan denied your request. The Plan says the enrollee does not need an intensive team for care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image (D0382) provided on April 7, 2021.

You asked the Plan to pay for the dental service. You say that you went for an implant consultation. You say that you were advised you needed imaging to determine if there was enough bone for an implant. You say that you were advised the imaging would not be covered. You also say that you were never told if you qualified for an implant or not. The Plan denied your request. The Plan says cone beam CT image is not listed as a covered service. The Plan also says that you signed a financial agreement the date of service agreeing to the $226 copayment for the cone beam CT.

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 cone beam CT image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) image (D0382) provided on April 7, 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 requested item. You say that a BiPAP has been ruled out in controlling her carbon dioxide levels. The Plan denied your request. The Plan says the service s could alternatively be provided by a BiPAP device
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 requested item. Our physician reviewer found that the enrollee has severe COPD and reported carbon dioxide retention, although this is not confirmed with an arterial blood gas while she is awake and stable. The ventilator is to be used as BiPAP, and a ventilator used in this way is not covered by Medicare. Certain BiPAP devices can provide the AVAPS mode of support. Therefore, a home ventilator is not medically necessary for this patient.
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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for counseling sessions provided on November 12, 2020.
You asked the Plan to pay for Psychotherapy (90837). You say that the Plan told you there was a mistake with the authorization, but half the claims were not reprocessed. The Plan denied your request. The Plan says that the service did not match the authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide the requested authorization documentation so authorization could not be determined. Therefore, we decided that the Plan has to pay for counseling sessions provided on November 12, 2020.
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.