Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 9, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee requires additional time in the current setting to receive treatment and discharge home safely. The enrollee is having ongoing thoughts of suicide and self-harm. The Plan denied your request. The Plan says as of November 9, 2021, the criteria for inpatient behavioral health services are not met. The enrollee may be stepped down to a less intensive level of outpatient care.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued inpatient psychiatric services is appropriate in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on October 30, 2021 with Major Depressive Disorder, recurrent Episode, Severe with Psychotic Features. Based upon review the records provided 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 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 she did not have dangerousness to herself or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. 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. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 9, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 9, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from a non-participating vendor.
You asked the Plan to pre-approve the hearing aids. You say that your ENT and audiologist are in-network and were recommended as reputable providers from your primary care physician. You say that hearing aids are necessary and should be covered. The Plan denied your request. The Plan says hearing aids that are not TruHearing brand or received from a non-participating provider are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are TruHearing brand and received from a participating provider.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from a non-participating vendor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 10, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient psychiatric care is medically necessary for this enrollee. The Plan denied your request. The Plan says as of November 10, 2021, psychiatric care at the inpatient acute level is no longer medically necessary. At this time the enrollee was calm and cooperative with a stable mood and no thoughts of self-harm or harming others. The enrollee may be stepped down to a less intensive level of care.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on November 2, 2021 with Major Depressive Disorder, Single Episode, Severe without Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of 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 he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 10, 2021, forward and could be treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 10, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 26, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service needs to be rebilled with modifier 26.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 88305 is level IV tissue exam by pathologist. We find that CPT code 88305 has a PC/TC indicator of 1. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on March 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no pharmacy benefit with this plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine for the enrollee
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve the PMD and battery. We decided that the Plan does not have to pre-approve the arm rest.

You asked the Plan to pre-approve the PMD and accessories. You say that the items are medically necessary. The Plan says that the items are not medically necessary.

We decided that the Plan has to pre-approve the PMD and battery.

The Plan follows Medicare rules. Medicare rules say that Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for a person who meets the criteria listed in the Medicare Rules section of this letter. 

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 PMD and accessories. Our reviewer says that the enrollee does need the PMD and battery. Our physician reviewer found the enrollee underwent a physical therapy evaluation and cannot operate a manual wheelchair, nor can the enrollee's mobility deficit be helped by the use of a walker, cane or 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 PMD and battery have been met. Therefore, we decided that the Plan has to pre-approve the PMD and battery.

We also decided that the Plan does not have to pre-approve the arm rest.

The Plan follows Medicare rules. Medicare rules say that adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair. 

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 arm rest. Our reviewer says that the item is not medically necessary. Our physician reviewer found the case file does not contain documentation that the enrollee requires an arm height that is different from that available using nonadjustable arms, and that they spend at least two hours per day in the 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 arm rest have not been met. Therefore, we decided that the Plan does not have to pre-approve the arm rest.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says there is no documentation that shows the enrollee is capable of being weaned at this time.
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 that the enrollee is capable of being weaned at this time. There is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on May 19, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this copayment should be waived because you have a colonoscopy every 5 years because of polyps. You stated that this procedure has always been routine without a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $200 copayment for outpatient surgery and services at a hospital outpatient facility.
You have been asked to pay a $200 copayment for the diagnostic colonoscopy. We looked at the records associated with this colonoscopy. The provider billed this as a diagnostic, not screening, colonoscopy. The medical records show that this colonoscopy was performed because of a personal history of polyps. According to your Evidence of Coverage, if you are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for this existing medical condition. That is why the copayment applies here. 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 waive the copayment for the diagnostic colonoscopy you had on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Farxiga tablet.
You asked the Plan to pre-approve Farxiga tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Farxiga tablet.
Benefits for Farxiga tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 14 Day Sensor for the
enrollee.
You asked the Plan to provide coverage for equipment. You say that this equipment is medically necessary for
the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.
Our Medical Director looked at the case file. At issue is coverage for a Freestyle Libre 14-day sensor.
The Maximus Physician Reviewer determined that the requested sensor is medically necessary. The reviewer
determined that the enrollee is performing frequent testing, is insulin treated with multiple daily injections,
frequently adjusts the doses, and is being closely monitored.
The Plan argues that the enrollee's physician indicated that the enrollee was not adjusting her own insulin, and
when the pharmacy computer records were checked, it was noted that glucose strips were only filled enough to
test twice a day. The Plan is correct in this case. There is insufficient clinical documentation in the case file to
demonstrate that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee based on
blood glucose monitoring or continuous glucose monitoring testing results. The documentation is insufficient
to demonstrate that the coverage criteria for a Freestyle Libre 14-day sensor, as established by Medicare Local
Coverage Determination L33822, have been met in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for a Freestyle Libre 14 Day Sensor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular
partial denture (D5214).
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you would like to have dentures made at a new facility because your current dentures were poorly made and ill
fitted. The Plan denied your request. The Plan says these services are only covered 1 time in a 60-month
period. The Plan also says that you have already received these services within that time period.
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, you are limited to 1 complete or partial
denture every 5 years. The record shows that you received a complete maxillary denture (D5110) and a
mandibular partial denture (D5214) on July 7, 2020, and your maxillary and mandibular denture benefits have
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture
(D5110) and a mandibular partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided April 6, 2021.

You asked the Plan to pay for the diagnostic service. You say that please review the requested medical notes for review and reprocess the claim for payment. The Plan denied your request. The Plan says the units exceeds the medically unlikely edits. There is no additional documentation supporting an additional study which was billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that the submitted documentation supports 1 unit of 93970. 2 units of CPT code 93970 are not supported in the medical record. The medical record only supports the submitted documentation supports 1 unit of 93970. units of CPT code 93970. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that this is a proven surgical procedure which would benefit the enrollee. The Plan denied your request. The Plan says there is not sufficient literature support for this 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 the Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer is experimental. More research is needed to show safety and efficacy.

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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
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 need IRF care to return to your prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can use a BiPAP for his needs.
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 portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. You have chronic respiratory failure. The medical records are insufficient to support the ventilator device as there was no clear abnormal results from pulmonary function tests or arterial blood gases tests on BiPAP provided or other evidence that they had failed BiPAP with average volume assured pressure support at home or would be inappropriate for such to justify this request. Our physician reviewer found that your condition does not meet Medicare criteria for a portable
ventilator. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.