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

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA). 
 
You asked the Plan to pre-approve a CTA. The Plan denied your request. The Plan says that according to the 
National Coverage Determination (NCD) 220.1 Computed Tomography, sufficient information must be 
provided with claims to differentiate CT scans from other radiology services and to make coverage 
determinations. 
 
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 a CTA. Our reviewer says that a CTA is 
medically necessary. Our physician reviewer found that this enrollee has atherosclerotic disease involving 
multiple large arteries including the aorta and has undergone repair of both the aorta and a femoral-femoral 
bypass. Even though there are distal pulses, the proximal femoral-femoral bypass was noted to be occluded, the 
distal flow was deemed to be due to collateralized flow. Given the complexity of the surgical history in this 
case it is reasonable to pursue CTA evaluation of the abdomen and pelvis and runoff. 
 
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 CTA have been met. Therefore, we decided that the Plan has to pre-approve a 
CTA.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiation evaluation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a radiation evaluation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a radiation evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to an 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. The patient appears to be stable and improving and should only require short-term additional acute care services that can be completed at the current facility until more appropriate for a lower level of care. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve foot inserts. You say that without the inserts, you will have to have surgery. 
Both of your feet are currently taped up and your job requires a level of walking, and the condition is affecting 
your job. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the periodontal maintenance (D4910). You say that your dentist has 
recommended the periodontal maintenance four times per year. The Plan denied your request. The Plan says 
the service exceeded the frequency limitation in the benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage. The Plan also has a maximum benefit 
of one periodontal maintenance every six months. The periodontal maintenance is not covered because the Plan 
paid for periodontal maintenance on November 9, 2021, which exhausted your benefit. Therefore, we decided 
that the Plan does not have to pre-approve periodontal maintenance (D4910) to be provided by a network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric services provided on March 12, 
2021 to March 22, 2021 an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient services. You say that the enrollee arrived at your facility suffering 
from severe bipolar disorder, depression and anxiety. The insurance coverage was unknown during admission 
therefore authorization could not be requested. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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. 
 
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. 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 psychiatric services provided on 
March 12, 2021 to March 22, 2021 an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health partial hospitalization. 
 
You asked the Plan to pre-approve behavioral health partial hospitalization. You say that you are very anxious, 
and you can't get to sleep even with medications. You say that you are very upset with uncontrollable crying, 
anger, and you are not interested in anything you like to do and you can't concentrate in your daily life. The 
Plan denied your request. The Plan says the patient has no acute symptoms or psycho-social factors that pose 
imminent risk or potential for imminent risk to herself, others, or property. Documented clinical findings do not 
justify the level of care requested. Priority coordination of outpatient services is required 
 
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 behavioral health partial 
hospitalization. Our reviewer says that the requested behavioral health partial hospitalization is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that based upon review the 
records provided, you were not showing any dangerousness to self or others and has not been exhibiting severe 
psychological or psychiatric impairment requiring this level of care. You were not showing any dangerousness 
to self or others, tolerating medication and not showing any perceptual disturbance, psychosis or aggressive 
behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the partial 
hospitalization level of care rather than a lower level of care as you did not have any suicidal or homicidal 
thoughts or behavioral disturbance and her symptomatology could be treated at a lower level of care. The 
health Plans denial of continued partial hospitalization treatment for the dates in question appears appropriate. 
You did not appear to require partial hospitalization treatment. You were not showing any severity of 
psychological or psychiatric illness. Based upon review the records provided, you do not meet the criteria for 
treatment at partial hospitalization level of care and could have been treated in a lesser restrictive setting as you 
were not showing any suicidal or homicidal ideation and was not showing any psychosis or aggressive 
behaviors 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health partial hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve behavioral health partial hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options (K0861, E2313, E2311, E0956).
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options. You say that
this wheelchair is medically necessary. The Plan denied your request. The Plan says the requested power
features exceed the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that wheelchair features are only covered when 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 group 3 power wheelchair with
multiple power options. Our reviewer says that the requested features are not medically necessary. Our
physician reviewer found the request for the expandable controller exceeds the patient's medical need. The
documentation is conflicting on the patient's strength. Given the normal grip strength and ability to perform
75% of activities of daily living independently the patient should be able to control any power options with
their own switches. The documentation does not reveal that the patient has spasticity that needs to be managed
with a power seating system. While the patient may be able to safely use the requested wheelchair the
documentation does not reveal that the requested chair with multiple power options is 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 the group 3 power wheelchair with multiple power options have not been met.
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple
power options (K0861, E2313, E2311, E0956).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the member's needs can only be met in 
an LTACH> The Plan denied your request. The Plan says that the enrollee is receiving the care he needs in the 
hospital where he is now. 
 
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. The patient 
appears to be improving and should only require short-term additional acute care services that can be 
completed at the current facility until more appropriate for a lower level of care. The patient does not require 
services at the LTACH that are not already available at the current facility. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for weekly international normalized ratio (INR) 
self-testing provided from November 17, 2020, to September 10, 2021.  
 
You asked the Plan to waive the cost share for INR self-testing. You say that there services were fraudulently 
submitted, and you do not want to pay for these tests. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
 
 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 $30 
copayment for services by a specialist. The Plan contract also says that there is a $300 deductible which applies 
to certain items and services. The Plan deductible applies to services by a specialist. 
 
The record shows weekly INR test were done from November 17, 2020, to September 10, 2021. The amount of 
$230.22 was applied to the deductible. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $300 deductible which applies to services by a specialist. This cost sharing is a contractual 
obligation that had not been met at the time the INR self-testing was received from January 5, 2021, to 
February 2, 2021. 
 
You have been asked to pay a $30 copayment for each INR self-test from November 17, 2020, to December 
29, 2020, and from February 10, 2021, to September 10, 2021 ($30 copayment x 35 tests = $1,050). You have 
been asked to pay a total of $1,280.22 ($1,050 copayments + $230.22 deductible = $1,280.22).  INR self-
testing falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 cost share for weekly international normalized ratio (INR) self-testing 
provided from November 17, 2020, to September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Anoro Ellipta.
You asked the Plan to pre-approve the Anoro Ellipta. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 the Anoro Ellipta.
Benefits for the Anoro Ellipta 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix (J1447).
You asked the Plan to pre-approve Granix. You say that this drug is medically necessary for the enrollee's treatment. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Granix. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 80-year-old male with diagnoses of malignant neoplasm of head, face and neck, pancreatic/cholangiocarcinoma and neutropenia, unspecified. In this case, the Plan requires a trial of Nivestym and Zarxio before they will approve the requested drug, Granix. Based on the medical records provided there is no indication that the patient has tried and failed the required drugs. Furthermore, based on the medical records provided and the Medicare-approved major drug compendia there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix (J1447).
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower 
level of care for any ongoing long-term care (LTC) needs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 63047 is "Laminectomy, facetectomy and foraminotomy 
(unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or 
lateral recess stenosis]), single vertebral segment; lumbar." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 22633 includes CPT 63047 
when done at the same level, as in this case. 
 
We looked at this coder'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 pay for surgical services provided to the enrollee on October 4, 2021.