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

We decided that the Plan has to pre-approve a facility-based polysomnography (PSG).

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says that a home sleep study can be attempted for continued symptoms, as suggested at the original diagnosis.

The Plan must follow Medicare rules. Medicare rules say that services are covered 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 study. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found a diagnostic attended PSG is considered reasonable and medically necessary. This enrollee has mild obstructive sleep apnea, but also has symptoms consistent with REM behavioral disorder. This was not mentioned in the report of the initial PSG and may be worse now. A full night diagnostic PSG would help with assessing these symptoms and treatment. A home sleep study will not help with this assessment and is not indicated.

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 study have been met. Therefore, we decided that the Plan has to pre-approve a facility-based polysomnography (PSG).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the DexCom G6 Receiver.

You asked the Plan to pre-approve the DexCom G6 Receiver. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the therapeutic continuous glucose monitor.

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 DexCom G6 Receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve the DexCom G6 Receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. You say that it would be difficult to perform facet joint injections given the amount of dextroscoliosis, facet hypertrophy, and osteophytes. The Plan denied your request. The Plan says there has not been a second set of diagnostic medial branch blocks.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 services. Our physician reviewer found that the enrollee has chronic low back pain and scoliosis. She had a single set of diagnostic medial branch blocks, which was negative. It only achieved 50% pain relief for a brief period of time. Since it was negative, it should not be repeated, and alternate pain generators sought. Therefore, the request is 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee has signs and/or symptoms of heart disease.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. The rules say that CPT code 75571 is not a covered service. Therefore, we decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed rail pads.
You asked the Plan to pre-approve hospital bed rail pads. You say that the requested items are a matter of safety and not of convenience. The Plan denied your request. The Plan says rules for coverage of the requested items have not been met.
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 serves a preventive purpose rather than one that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve hospital bed rail pads.
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 care could be received in another setting.

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 surgical treatment of a distal femur fracture. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, head or brain (CPT code 70450), for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says that a CT head of brain is not recommended for initial staging/work up prior to preoperative systemic therapy/additional workup for newly diagnosed invasive breast cancer.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our physician reviewer found it would be medically appropriate to determine the status of any possible metastases for this enrollee before proceeding with mastectomy to remove the cancer. Therefore, CT head is appropriate at this point.

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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve CT, head or brain (CPT code 70450), 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS HF System (CPT code C2624 and 33289), 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 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 services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure (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 like this one. There is also longer-term follow-up data to recommend its use in post approval marketing studies as well. It would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule and would not be considered investigational in this situation nor require enrollment in a a CMS approved IDE trial. 

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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS HF System (CPT code C2624 and 33289), 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 LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged
hospitalization and close physician monitoring. The Plan denied your request. The Plan says the records do not
show that it is medically necessary to be in a LTACH in place of an acute care 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 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 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, 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 LTACH services.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for left hip pain, diverticulitis and
a urinary tract infection. Your 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.
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where 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, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the dental item. You say that your mouth guard is essential and a necessity for my health and well-being. You say that it should be covered as a medical equipment. You say that you were advised by a plan representative that if the mouth guard is for Bruxism, that you can claim coverage for medical equipment. You say that this mouth guard is for not only Bruxism, but to prevent biting your tongue or the inside of your cheeks, as well as headaches. The Plan denied your request. The Plan says occlusal guard is not listed as a covered service. The Plan also says that any services not listed are not covered.
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).
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 requires long term acute level of care with a highly specialized care team. The Plan denied your request. The Plan says the enrollee can safely receive care in another setting.

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 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, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network provider.
You asked the Plan to pre-approve a second opinion. You say that the in-network specialist's priorities do not align with your values. The Plan denied your request. The Plan says there is appropriate care available in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network provider.
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. The Plan denied your request. The Plan says the enrollee's care is
not complex, and she does not need a team of providers.

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 as a past medical history of diabetes, hypertension, lumbar spinal stenosis. She is living in an
assisted living facility with increasing debility and weakness. Her medical problems are stable. There are no
complex nursing needs. She does not require treatment by multiple therapies, including either physical or
occupational therapy, in an intensive rehabilitation therapy 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.