Persius/hicric huggingface dataset:
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 the records provided support the need for a portable ventilator. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested lung device.
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 the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a bi-level positive airway pressure (BiPAP) machine
with average volume-assured pressure support (AVAPS) capability. The Plan has indicated such a device is available. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from
December 10, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee would benefit
from continued hospitalization for further treatment and preparation for discharge. The Plan denied your
request. The Plan says as of December 10, 2021, ongoing psychiatric care at the inpatient level is not medically
necessary. The enrollee can be discharged and treated in a less restrictive setting.
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 admitted to the acute inpatient
psychiatric hospitalization on November 30, 2021, with Bipolar Disorder, Most Recent Episode Depressed.
Based upon review of 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, no
auditory or visual hallucinations and no aggressive behaviors. This patient was compliant and cooperative with
treatment. 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, hallucinations or aggressive 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 December 10, 2021, forward 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 inpatient psychiatric care from December 10, 2021,
forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on March 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the out-of-network lab services. You say that these services should be covered because they were ordered by the referring provider. The Plan denied your request. The Plan says unauthorized, non-plan care is not a covered benefit.
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 provider in this case is not a network provider with the Plan. The ordering provider is also not a network provider with the Plan. 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 lab services provided on March 15, 2021, by an out-of-network (OON) provider.
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 the enrollee will clearly benefit from an IRF admission to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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 the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81345) provided May 24, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.
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, we have confirmed that code 81345 shares a bundled relationship with code 0089U which was also billed. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81345) provided May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an OON provider.
You asked the Plan to pre-approve OON services. You say that the enrollee was having shortness of breath.
The Plan denied your request. The Plan says there are in-network providers that can provide this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
cardiology services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.
You asked the Plan to pre-approve dentures. You say that you need dentures for your overall health and wellbeing.
The Plan denied your request. The Plan says dentures are not covered by your dental benefit.
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, dentures are not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower
dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 non-emergency transportation trips (A0100).
You asked the Plan to pre-approve the non-emergency trips. You say that the enrollee is ambulatory and needs
non-emergency transportation to his dialysis treatments. You also say that the enrollee currently has no means
of transportation to and from dialysis. The Plan denied your request. The Plan says the enrollee has used 12 out
of 12 trips and does not have benefits left.
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 a maximum of 12 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve 60 non-emergency transportation trips (A0100).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml subcutaneous injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.
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 the injection. Our reviewer says that the
requested injection is not medically reasonable or necessary. Our physician reviewer found the record indicates
that the enrollee has age related osteoporosis without osteoporotic fracture. The record indicates that the
enrollee has tried and failed an oral bisphosphonate. However, the provided records do not indicate that the
enrollee has tried and failed all of the plan's preferred step one alternatives. The record does not indicate that
the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one
alternative, zoledronic acid. All of the elements of the coverage criteria are not satisfied.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia 60mg/ml subcutaneous injection for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast cancer genetic testing.
You asked the Plan to pre-approve the services. You say that you qualify for this testing due to family history. The Plan denied your request. The Plan says there are no signs of breast cancer and the exam was normal.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the services, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes without a personal diagnosis of cancer. Therefore, we decided that the Plan does not have to pre-approve breast cancer genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the supplies for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM supplies. You say that you need these sensors so you can check your blood sugar. The Plan denied your request. The Plan says this is not covered by Medicare for enrollees who do not require insulin for their diabetes treatment.
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 use insulin
with at least three daily administrations. Based on this information, we decided that Medicare rules for
coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to preapprove
the supplies for a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation, vision testing, and treatment to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a consultation, vision testing, and treatment to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
You asked the Plan to pre-approve compression stockings. You say that this should be covered because you have severe swelling in your legs caused by a blockage or collapse in a deep vein in your abdomen. The Plan denied your request. The Plan says the requested item is a support hose and is not considered durable medical equipment and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dermatology visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the dermatology visit. You say that you have a family history of skin cancer, and you have not had a skin check. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the dermatology
visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
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 electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need to check your blood pressure immediately as you suffer from dizziness on a daily basis, and you need to be more in control of your blood pressure. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
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 intensive physical therapy to relearn daily
activities. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF
services do not meet the requirements for approval.
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. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Rituximab (J9312).
You asked the Plan to pre-approve Rituximab. You say that the preferred alternatives present a financial hardship for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug 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 Rituximab. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
Plan requires a trial of Ruxience and Truxima before they will approve the requested drug. The requested
medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or
would have an adverse effect from, the Plan's preferred step-one alternatives.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not
have to pre-approve treatment with Rituximab (J9312).