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

We decided that the Plan does not have to pre-approve continuation of an inpatient psychiatric admission and services from February 1, 2022, forward.

You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee does not currently have a safe discharge plan and cannot go home or be moved to the personal care home at this time. The Plan denied your request. The Plan says as of February 1, 2022, the enrollee does not meet the criteria for psychiatric care at the inpatient level and can be stepped down to a less restrictive 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 of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on January 25, 2022, with Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance. Based upon a review of 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. 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 a review of the records provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 1, 2022, 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 continuation of an inpatient psychiatric admission and services from February 1, 2022, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (Ferric carboxymaltose).

You asked the Plan to pre-approve Injectafer. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not been met in this case.

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 Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of Myelodysplastic syndrome, unspecified. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. In this case, the enrolle has not tried and failed these drugs. In addition, the documentation does not support that Infed and Venofer would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (Ferric carboxymaltose).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the diagnostic test provided on August 31, 2020. We also decided that the Plan does not have to waive the copayments for the diagnostic tests provided on March 1, 2021, and September 15, 2021.

You asked the Plan to waive the copayments for diagnostic test. You say that the copayments keep on increasing and you do not understand why you are also paying a copayment for an office visit. The Plan denied your request. The Plan says the provider billed for these services and the proper copayments were applied.

We decided that the Plan has to waive the copayment for the diagnostic test provided on August 31, 2020.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a complete Evidence of Coverage (EOC) for 2020. You say that the enrollee had a copayment of $40 for August 31, 2020. Without a EOC for 2020, the Plan has not shown that its decision to apply this cost-sharing is correct or justified. Therefore, we decided that the Plan has to waive the copayment for the diagnostic test provided on August 31, 2020.

We decided that the Plan does not have to waive the copayments for the diagnostic tests provided on March 1, 2021, and September 15, 2021.

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 $50 copayment for each Medicare-covered outpatient diagnostic procedure and test in an office setting. On March 1, 2021, and September 15, 2021, you were charged a $50 copayment for each visit. The total copayment amount was $100 ($50 copayment + $50 copayment). 

You have been asked to pay a $100 copayment for the diagnostic tests. The diagnostic tests falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 copayments for the diagnostic tests provided on March 1, 2021, and September 15, 2021.

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 continuation of an inpatient psychiatric admission and services from February 7, 2022, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you need additional inpatient mental health care. The Plan denied your request. The Plan says as of February 8, 2022, you no longer meet the criteria for psychiatric care at the inpatient level.
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 psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on January 21, 2022, with Major Neurocognitive Disorder, Most Likely Due to Alzheimer's Disease with Behavioral Disturbance. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations, and were 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. 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 your condition or for the purpose of diagnosis. Based upon the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 8, 2022, and could have been 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 continuation of an inpatient psychiatric admission and services from February 7, 2022, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's medical condition requires further evaluation and treatment in the acute
care hospital.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure and chronic obstructive pulmonary disease (COPD) exacerbation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815).

You asked the Plan to pre-approve a PET-CT scan from skull base to mid-thigh. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that the use of FDG PET for determining initial treatment strategy in prostate cancer is non-covered. Based on this information, we decided that Medicare rules for coverage of a PET-CT scan from skull base to mid-thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for the
enrollee's arthritis. The Plan denied your request. The Plan says the coverage criteria for the requested
compression stockings have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings
identified with code A6545.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) services.

You asked the Plan to pre-approve RFA services. You say that this is medically necessary for your chronic pain. The Plan denied your request. The Plan says the services have been exhausted based on Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

We looked at the file and Medicare rules. In this case, this would exceed Medicare's limit for covered RFA services. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says your request is not a covered benefit.
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 power seat elevation system have not been met. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Destruction of upper or middle spinal facet joint nerves using imaging guidance (64633) and Destruction of upper or middle spinal facet joint nerves with imaging guidance (64634) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because records do not show that the enrollee had a second medial branch block.
The Plan must follow Medicare rules. Medicare rules say that RFA is covered if the LCD criteria is met. 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 requested services are not considered medically reasonable and necessary in this case. There is no documentation of a second set of diagnostic medial branch blocks (MBB) as required. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 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 Destruction of upper or middle spinal facet joint nerves using imaging guidance (64633) and Destruction of upper or middle spinal facet joint nerves with imaging guidance (64634) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211).
You asked the Plan to pre-approve a partial upper denture. You say that the enrollee needs a new partial upper
denture because her dog ate her last denture that was purchased on November 10, 2021. The Plan denied your
request. The Plan says the service is only covered once per every 5 plan years.
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 Plan covers a partial
upper denture once every five plan years.
We looked at the file and Medicare rules. The records show you received an upper partial denture on
November 10, 2021; therefore, you have exhausted your benefit for this service. Based on this information, we
decided that the Plan's rules for coverage of a partial upper denture have not been met. Therefore, we decided
that the Plan does not have to pre-approve a partial upper denture (D5211).
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 indicating medical necessity for 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you have severe carpal tunnel with arthritis
so your hand is numb. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a
therapeutic continuous glucose monitor (CGM).
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
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, require frequent selfadjustment
of insulin dosage based on the blood glucose testing results, have had an in-person visit with their
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore,
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel testing.
You asked the Plan to pre-approve targeted genomic sequence analysis panel. You say that your doctor says this test is medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for this testing.
The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis panel testing will be denied automatically as not medically necessary. We looked at the file and Medicare rules. This test is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan drops.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug
benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Zioptan drops.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.