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

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested home ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the Life2000 System is not medically necessary. This system is not a true ventilator. It is positive pressure oxygen to be used during activity. There is inadequate evidence of efficacy for any lung disease, including chronic obstructive pulmonary disease (COPD). Coverage criteria are not met for a home ventilator or for nocturnal ventilatory support; there is no documentation of CO2 retention.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you meet the criteria for needed skilled nursing services. The Plan denied your request. The Plan says you have no daily skilled nursing or therapy needs.  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 services. Our physician reviewer found that you presented to the acute hospital with weakness and hyponatremia. At time of discharge, you were walking 150 feet with a rolling walker with stand-by assistance and was stand-by assist for transfers and supervision for activities of daily living. There is no documentation that you require skilled nursing or therapy services on a daily basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says despite multiple outreach attempts, medical necessity cannot be established.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you are unable to accomplish one or more mobility-related activities of daily living due to ambulatory dsyfunction. There is no indication that you would be unable to use an alternative assistive device or a manual wheelchair.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient rehabilitation and skilled nursing services provided on June 23, 2021 to June 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the inpatient services. You say that these services were necessary following a separate hospital admission related to a fall. The enrollee was in a state other than their home state at the time and was unable to return home for continued care. The Plan denied your request. The Plan says the services at issue were provided by an out-of-network facility and prior authorization was not requested prior to 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  In addition, the Plan requires prior authorization for inpatient services.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue, and there is no evidence that prior authorization was requested. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the inpatient rehabilitation and skilled nursing services provided on June 23, 2021 to June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.

You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says the enrollee has not tried and failed Infed and Venofer.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Feraheme. Our physician reviewer found that the enrollee has iron deficiency anemia. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or likely have adverse effects 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).  You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.  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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment.  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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on January 28, 2021, and the limited oral exam (D0140) provided on March 18, 2021.  You asked the Plan to pay for the dental services. You say that you were insured at the time of services, and this dental care should be covered in full. The Plan denied your request. The Plan says they have agreed to cover the periodic oral evaluation (D0120) which was previously submitted with code D9999. The billing has been corrected, and this is a covered service. However, the decision to not pay the full cost for the dental cleaning and limited evaluation is upheld, as these services were processed correctly. When you choose to see an out-of-network dental provider, you may be billed for any amount greater than what the Plan pays for services.  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. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for dental cleanings (D1110) and a $0 copayment for limited exam to evaluate a problem (D0140). However, if you choose to see an out-of-network dentist, you might be billed for charges above what the Plan pays, even for services listed as a $0 copayment. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network provider, you might be billed for any amount greater than what the Plan pays.  You have been asked to pay $54 for the cleaning provided on January 28, 2021. The provider billed the Plan $102 for the cleaning. The Plan's allowed amount for this service is $48. This is the amount that an in-network provider would accept as full payment for this service, but out-of-network providers do not have this agreement and are allowed to bill you for any amount that exceeds the Plan's payment. The Plan paid the full $48 allowed amount, and you are responsible for the amount that exceeds the Plan's price for this service ($104 - $48 = $54).  You have been asked to pay $61 for the limited oral evaluation provided on March 18, 2021. The Provider billed the Plan $99 for the exam. The Plan's allowed amount for this service is $38. The Plan has paid the full $38 allowed amount, and you are responsible for the amount billed by the provider that exceeds the Plan's price for this service ($99 - $38 = $61).   This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay any additional amount for the dental cleaning (D1110) provided on January 28, 2021, and the limited oral exam (D0140) provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170).  You asked the Plan to pre-approve the additional routine transportation mileage. You say that the additional mileage is needed. The Plan denied your request. The Plan says the request exceeds the benefits for routine transportation.  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. The Plan covers routine transportation when the destination is 50 miles or less from the starting location.   We looked at your request, the records in the case file, and the rules. The destination in this case exceeds 50 miles from the starting point (83 miles). Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170).
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pre-approve genetic testing (81479).  You asked the Plan to pre-approve the genetic testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that genetic testing is considered medically necessary when the results from testing will be used to directly impact the treatment or the management of the patient's condition.  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 genetic testing. Our reviewer says that the requested genetic testing is medically necessary. Our physician reviewer found patient was found to have greater than 10 adenomatous polyps on colonoscopy. According to the NCCN Guidelines this meets panel testing for possible polyposis syndrome.  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 genetic testing have been met. Therefore, we decided that the Plan has to pre-approve genetic testing (81479).   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 an inpatient behavioral health admission.

You asked the Plan to pre-approve an inpatient behavioral health admission. You say that the services are medically necessary. The Plan denied your request. The Plan says the provided documentation does not show that the requested services are 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 an inpatient behavioral health admission. Our reviewer says that the inpatient behavioral health admission is not medically necessary. Our physician reviewer found the provided documentation indicates it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The reviewer found that the enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to herself or others but was compliant with her treatment. The reviewer found that it did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Therefore, the reviewer found that the behavior health admission was 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 an inpatient behavioral health admission have not been met. Specifically, the file shows that the enrollee did not have dangerousness to herself or others but was compliant with her treatment. Therefore, we decided that the Plan does not have to pre-approve an inpatient behavioral health admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001).  You asked the Plan to pre-approve a standard manual wheelchair (K0001). You say that the requested standard manual wheelchair (K0001) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested standard manual wheelchair (K0001).  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 a standard manual wheelchair (K0001). Our reviewer says that the enrollee does not meet criteria for the requested standard manual wheelchair (K0001). Our physician reviewer found the requested standard manual wheelchair (K0001) is not medically necessary per LCD L33788. The documentation notes the enrollee has a mobility deficit, but the documentation does not reveal that the deficit is unable to be helped by an assistive device as the enrollee is able to use crutches. The documentation does not reveal that the mobility deficit significantly impairs mobility related activities of daily living (MRADLs) in the home. The documentation does not reveal that the requested wheelchair can be maneuvered safely in the home and will significantly improve MRADLs in the home.  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 standard manual wheelchair (K0001) have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve tricuspid heart valve repair (CPT code 0646T), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee is a very complex young person who has been discussed extensively with the multi-disciplinary heart team with LVAD sever AI, severe MR, and severe TR. You state the enrollee with post-partum cardiomyopathy and biventricular failure options are limited. You state the enrollee is not a cardiac transplant candidate secondary to psychosocial issues and ABO blood type. The Plan denied your request. The Plan says the service is 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found devices for transcatheter tricuspid valve repair are considered investigational in the United States.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve tricuspid heart valve repair (CPT code 0646T), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve minimally-invasive percutaneous sacroiliac fusion 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 there is a presence of bilateral sacroiliac joint pain and chronic pain secondary to post-laminectomy syndrome with spinal cord stimulator placement.  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 requested procedure is experimental for degenerative back pain. There is no sacroiliac joint instability, fracture, or lesion.  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 minimally-invasive percutaneous sacroiliac fusion 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found you were admitted to the hospital for non-surgical management of multiple fractures after a fall. You are now medically stable with 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.