Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expanded controller, harness, and electrical connection for a power wheelchair.

You asked the Plan to pre-approve expanded controller, harness, and electrical connection. You say that the enrollee's current power wheelchair is not meeting his needs, and due to his condition he needs all of these power functions. The Plan denied your request. The Plan says the denial of authorization for these accessories is correct, because the approved wheelchair components come with their own switches which are adequate for the enrollee given normal strength, function, and range of motion in his left upper limb.

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 expanded controller, harness, and electrical connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the requested expanded controller, harness, and electrical connection are medically reasonable and necessary given the already approved wheelchair and components. The records document that the enrollee has adequate strength and function of the left upper extremity to control the wheelchair's power options with their own 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 expanded controller, harness, and electrical connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expanded controller, harness, and electrical connection for a power wheelchair.
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 requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for acute inpatient hospital care have not been 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 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 that, in general, a long term electroencephalogram is done for evaluation and classification of seizure disorders. In some cases there is a pre-defined length of stay indicated at the outset. In this case, the records provided for review did not specify the enrollee's anticipated length of monitoring, nor was it clearly specified as to why admission to the epilepsy monitoring unit was being ordered or arranged. Therefore it cannot be determined based on the information provided whether the enrollee's expected stay would span 2 midnights as required by the criteria for 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 hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be reviewed, such as a skilled nursing facility, outpatient setting, or home health 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for urinary tract infection and ileus after recent lumbar spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s) 33289 and C2624), for the enrollee.

You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee needs the device and procedure due to worsening heart failure as the current standard of care has not been effective and has only worsened the enrollee's condition. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

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 the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is also published expert opinion in the cardiology literature as to its appropriate use (4) as well as reasonable patient selection criteria (5), and FDA approved indications (6) all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and necessary, not investigational, and has clinical data, expert opinion and FDA approved indications to back up its use in selected appropriate clinical situations like this one. It would therefore meet the medical necessity and reasonableness criteria of the applicable CMS section 1862(a) 1(A) rule.

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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s) 33289 and C2624), for the enrollee.

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 admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a less intensive setting of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at the IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve respite care or private duty nursing services.
You asked the Plan to pre-approve respite care or private duty nursing services. You say that the enrollee needs respite care while the caregiver has surgery. The Plan denied your request. The Plan says respite care is not covered.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at the file and Medicare rules. Private duty nursing is not covered, and respite care is only covered under the hospice benefit. Based on this information, we decided that Medicare rules for coverage of respite care or private duty nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve respite care or private duty nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that these orthotics are necessary for the amount of time you spend on your feet every day. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a therapeutic CGM (K0553).
You asked the Plan to pre-approve CGM supplies. You say that you need the requested items. The Plan denied your request. The Plan says rules for a CGM and supplies 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a therapeutic CGM (K0553).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on August 23, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this claim was for a member whose death was pronounced during the ambulance services and the QL modifier is required. The Plan denied your request. The Plan says the claim was not billed according to CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0429 and A0425 is not supported in the record. Specifically, the record indicates the member was pronounced dead after the ambulance was called. These services must be billed with CPT code A0428 and modifier QL. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on August 23, 2020.
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 acute inpatient rehabilitation will help the enrollee with recovery. The Plan denied your request. The Plan says the enrollee does not require an intensive complex multidisciplinary approach to daily therapy.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you have dialysis three (3) days a week and is requesting more routine transportation trips. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The 53rd trip and beyond is not a covered benefit. The health plan contract says up to fifty-two (52) one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a permanent cardiac contractility modulation (CCM) therapy, administered by Impulse Dynamics' Optimizer system (CPT code 0408T), for the enrollee.
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records indicate a discrepancy as to the enrollee's NYHA heart failure classification. There are insufficient medical records to determine the medical reasonableness and necessity of the requested service. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a permanent cardiac contractility modulation (CCM) therapy, administered by Impulse Dynamics' Optimizer system (CPT code 0408T), 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of low back pain and is living at home with increasing difficulty with ambulation Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lumbar and thoracic spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that there were no x-rays submitted with the appeal.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has back pain and left leg pain. The enrollee has had previous therapy with anti-inflammatory medications and physiotherapy. Examination demonstrates hyporeflexia and decreased sensation in the left lower extremity. The requested service is medically necessary and reasonable for the diagnosis or treatment of 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lumbar and thoracic spine for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944) to prevent teeth grinding.
You asked the Plan to pre-approve the occlusal guard. You say that this mouth guard is necessary to protect your teeth and prevent further damage and a need for more extensive dental work. The Plan denied your request. The Plan says occlusal guards are not covered by Medicare or by either of the Plan's supplemental dental 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 pre-approve an occlusal guard (D9944) to prevent teeth grinding.