Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the total shoulder surgery may be safely performed with an observational 48 hour stay. Inpatient admission is not needed. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for a QLogic joystick, joystick mount hardware, Blue Egg switch, footplate, footrest, mount elevating leg rests, and attendant control for a power mobility device.
You asked the Plan to pre-approve power mobility device accessory repairs. You say that the enrollee has severe muscle weakness which is not getting any better. The Plan denied your request. The Plan says the denial of authorization for these repairs is correct, because these components are included in components the Plan already approved and the attendant control cannot be covered if a user-operated control is already approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-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 power mobility device accessory repairs. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee qualifies for the use of a power mobility device and already has a device that is in need of repairs. The Plan has authorized the majority of the requested repairs. The QLogic joystick, joystick mount hardware, blue egg switch, footplate, footrest, and mount elevating leg rests are not bundled and cannot be authorized separately. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power mobility device accessory repairs have not been met. In addition, the requested attendant control is not covered in addition to the already approved user-operated control. Therefore, we decided that the Plan does not have to pre-approve repairs for a QLogic joystick, joystick mount hardware, Blue Egg switch, footplate, footrest, mount elevating leg rests, and attendant control for a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM)
and supplies.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that codes A9276 and A9277 are for use with a nontherapeutic
CGM.
We looked at the file and Medicare rules. The requested services are supplies described by codes A9276 and
A9277. These services are used for a non-therapeutic CGM and Medicare does not cover these items.
Therefore, we decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor
(CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 5, 2020.
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore, the Place of Service code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81407, 81479, 81286, 81408, 80404) provided October 7, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says these tests are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The testing at issue is a cardiovascular risk panel. 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 pay for genetic testing (81407, 81479, 81286, 81408, 80404) provided October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on September 29, 2020.
You asked the Plan to pay for the incomplete endodontic therapy. You say that you believe the Plan should cover the $725 for the root canal that they initially agreed to pay. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 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 incomplete endodontic therapy (D3332) provided on September 29, 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 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 based on the documentation
provided, 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: 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 these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 17, 2021 with schizoaffective disorder. Based on the submitted records, it is not expected that he will improve in a reasonable period of time, as he does not have dangerousness to self or others and has no auditory or visual hallucinations. He is not showing any behavioral issues or delusions. It does not appear that active treatment is taking place. The continued inpatient psychiatric services are not reasonable or medically necessary for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.

You asked the Plan to pre-approve a spinal cord stimulator. You say that this request is medically necessary.
The Plan denied your request. The Plan says the requirements for approval for the spinal cord stimulator have
not been met and the request is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the request for the spinal cord stimulator is subject to
the criteria listed in the Medicare rules section including receiving a psychological examination prior to the
services rendered.

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 spinal cord stimulator. Our reviewer
says that the requested item is not medically reasonable and necessary. Our physician reviewer found the
enrollee is a 59-year-old woman who is borderline morbidly obese, has chronic low back and hip pain. She has
not had prior spine surgery. She does not have any evidence-based indication for a spinal cord stimulator trial.
She has not had a psychological evaluation. Therefore, the criteria for the spinal cord stimulator have not been
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spinal cord stimulator.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says that this level of care is not needed.
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 admission. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee requires skilled therapy services - i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment for the time period covered in the available records. Based on the medical records provided, this enrollee did require the services on an inpatient basis, only in a skilled nursing facility setting for the time period covered in the available records. 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 been met. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
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 an implantable loop recorder.
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested implantable loop recorder is medically necessary. The Plan denied your request. The Plan says the requested implantable loop recorder 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 an implantable loop recorder. Our reviewer says that the requested implantable loop recorder is not medically necessary.
Our physician reviewer found the enrollee has a history of cerebral vascular accident (CVA) and mild LV dysfunction with mitral insufficiency. She has intermittent palpitations but no history of infrequent syncope. Based on the CMS NCD criteria she does not meet the applicable CMS 20.15 NCD criteria for implant of the ILR which requires intermittent syncopal episodes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for EEG with video services with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that these tests are necessary to determine the cause of the syncopal episodes The Plan denied your request. The Plan says the requested 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 a referral for EEG with video services with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, such as a SNF or home with home care.
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation services (99152, 99153).
You asked the Plan to pre-approve moderate sedation services. You say that the sedation services are medically
necessary. The Plan denied your request. The Plan says anesthesia is not the standard of care for a minimally
invasive procedure.
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 moderate sedation services. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found moderate sedation services have denied because based on Medicare
guidelines, the intravascular ultrasound (tiny camera inside your veins to see and operate) followed by
angioplasty (vein dilation) and stenting (placement of a tube to keep vessel open) with sedation that you and/or
your provider(s) is/are requesting do(es) not meet the requirements for approval. The review has determined
that the sedation services combined with this vascular surgery are not medically reasonable or 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 moderate sedation services have not been met. Therefore, we decided that the
Plan does not have to pre-approve moderate sedation services (99152, 99153).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS HF 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 that the services are not medically necessary.

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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has NYHA Class III heart
failure with reduced ejection fraction of 40 percent. She is on a high dose oral diuretic regimen also including
intermittent outpatient intravenous (IV) diuretics with recurrent and recent hospitalization in February of 2021
for decompensated congestive heart failure (CHF). Management of her heart failure with standard medical
therapy and relying on symptoms, weights and signs has not been effective in keeping her with minimal
symptoms and has resulted in acute recent hospitalizations despite close follow-up and regular diuretic
management. CardioMEMS device pulmonary pressure monitoring in this situation can provide additional
heart filling pressure data to better manage very complex regimens to optimize fluid status. Given the
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 has clinical data, expert opinion, and approved FDA indications to back up its use in
selected appropriate clinical situations, such as this enrollee's. The services are reasonable and 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 these services have been met. Therefore, we decided that the Plan has to preapprove
a CardioMEMS HF System.

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 pay for a lower partial denture (D5212) provided on November 11, 2020.
You asked the Plan to pay for a lower partial denture. You say that you were unaware that the provider was an opt out provider and you would like to be reimbursed for the service. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare opt out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for a lower partial denture (D5212) provided on November 11, 2020.