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

We decided that the Plan does not have to pre-approve a portable home ventilator.

You asked the Plan to pre-approve the requested item. You say that the device will help improve the enrollee's quality of life. The Plan denied your request. The Plan says there is no documentation that a BiPAP was utilized.

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 the requested item. Our physician reviewer found that the Life2000 ventilator was requested. This system is not a true ventilator. It provides positive pressure oxygen while the enrollee is awake. There is inadequate evidence to establish benefit of this system in the treatment of lung disease. In addition, the enrollee does not qualify for a home ventilator because there is no documentation of carbon dioxide (CO2) retention on an arterial blood gas obtained while she is awake and stable. There is also no documentation of BiPAP failure. Therefore, the requested device is not medically necessary

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.

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Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound coded as 76705 provided May 25,
2021.

You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says these services were not billed with an
appropriate modifier as required by the Medicare rules.


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 76705
a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line
item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the
Plan does not have to pay for the abdominal ultrasound coded as 76705 provided May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission and services from
September 29, 2021, forward
You asked the Plan to pre-approve a continued inpatient psychiatric stay. You say that the enrollee is a danger
to himself and would like the inpatient admission approved. The Plan denied your request. The Plan says under
Medicare guidelines, the request is not medically necessary because the records received show that the
enrollee's condition has improved, and he is no longer a threat to himself or others.
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 a continued inpatient psychiatric stay.
Our reviewer says that the continued inpatient psychiatric stay is not medically necessary. Our physician
reviewer found that the enrollee did not require inpatient mental health treatment beyond the dates in question
as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. 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 from September 29, 2021, forward and
could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation,
auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative
and compliant while not showing any acute threats to safety as the enrollee awaited placement.
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 continued inpatient psychiatric stay have not been met. Therefore, we decided
that the Plan does not have to pre-approve an inpatient psychiatric admission and services from September 29,
2021, forward
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have
reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to
prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a
practical matter, can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the provider has to replace aortic valves. The Plan denied your request. The Plan says there are network providers available.
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 out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on
August 11, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the record indicates that the enrollee has hypertension, arrhythmia and chronic kidney disease. The
record indicates that the requested service was desired by the enrollee as screening. The provided records do
not support the medical necessity and reasonableness of the requested service for the enrollee's condition.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the cardiovascular risk assessment testing provided on August 11, 2020
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 your specific needs cannot be met at a lower level of care in your geographic area. You say that you are transfusion dependent. You say that you are receiving chemotherapy at the same facility. You also say that you require bladder irrigation when you bleed. The Plan denied your request. The Plan says the requested LTACH care is not medically reasonable or necessary.
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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require 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 your diagnosis and condition, 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. Specifically, the file does not show that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the lower left leg x-ray provided on June 21, 2021.
You asked the Plan to pay for radiologic examination; tibia and fibula, 2 views (73590). You say that per the Plan lookup authorization is not required when performed in an office setting. The enrollee had surgery and the x-ray was for continuity of care. The Plan denied your request. The Plan says that prior authorization was not obtained as required.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. We looked at this the file and Medicare rules. The enrollee had surgery on April 11, 2021. It is reasonable to allow continuity of care. Based on this information, we decided that Medicare rules for coverage of radiologic examination; tibia and fibula, 2 views (73590) have been met. Therefore, we decided that the Plan has to pay for the lower left leg x-ray provided on June 21, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services for management of temporomandibular joint disorder.
You asked the Plan to pre-approve office visit (99214), cast supplies (A4580), closed treatment of temporomandibular dislocation, (21485), and application of interdental fixation device (21110). You say that treatment for TMJ is medically necessary. The Plan denied your request. The Plan says neither Medicare nor the Plan cover routine dental services, or oral appliances, for TMJ.
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 office visit (99214), cast supplies (A4580), closed treatment of temporomandibular dislocation, (21485), and application of interdental fixation device (21110). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the record indicates that the enrollee is being treated for temporomandibular joint dysfunction. This indication is excluded from coverage. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit (99214), cast supplies (A4580), closed treatment of temporomandibular dislocation, (21485), and application of interdental fixation device (21110). have not been met. Therefore, we decided that the Plan does not have to pre-approve services for management of temporomandibular joint disorder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.
You asked the Plan to pre-approve Vascepa. You say that the enrollee is responding well to the medication. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
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 Vascepa.
Benefits for Vascepa 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: Surgery
Decision: Favorable

We decided that the Plan has to pay for a tissue exam by a pathologist (88307) provided on April 20, 2021.
You asked the Plan to pay for a tissue exam. You say that the requested services were provided by a pathologist. The Plan denied your request. The Plan says that rules for payment have not been met because the provider at issue is a student.
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. In this case, the provider at issue is classified in the National Provider Identifier (NPI) Registry as a student in an organized health care education/training program. The provider's NPI profile has not been updated since 2014. However, Medicare records state that the provider is enrolled in the Medicare program as a pathology practitioner. The Plan's denial rationale is not supported in the Medicare records. Therefore, we decided that the Plan has to pay for a tissue exam by a pathologist (88307) provided on April 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office service provided on May 28, 2021 by an out-ofnetwork
(OON) provider.

You asked the Plan to pay for the office service. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the office service provided on May 28, 2021 by an out-ofnetwork
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that you have no one to take you to the doctor. The Plan denied your request. The Plan says you have exhausted your benefit.

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 10 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used 10 trips this year. 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 additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a positron emission tomography (PET).

You asked the Plan to provide positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). You say that you want to know how fast the cancer is growing but you are not considering treatment. The Plan denied your request. The Plan says you have declined additional treatment therefore criteria is not met.

The Plan must follow Medicare rules. Medicare rules say that Pet scan imaging is for initial and subsequent treatment strategy.

We looked at the file and Medicare rules. You have chosen to not have treatment. Based on this information, we decided that Medicare rules for coverage of positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) have not been met.
Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET).
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 do not want to go to a skilled nursing facility due to previously having fallen and injured yourself during a stay. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in - or 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: Favorable

We decided that the Plan has to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that you have chronic lymphedema and have developed open sores. You say that you have had hospitalizations due to infected wounds and sepsis. You say that the compression garments are required in order for lymphedema treatment to have any effect. The Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for compression stockings.
The Plan must follow Medicare rules. Medicare rules say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 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 compression stockings. Our reviewer says that the requested compression stockings are considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation in the medical record that the enrollee has developed wounds of her lower extremities, and this is reiterated in the appeal letter by the physician. As compression stockings would be an integral component of wound care for these lesions, and the wounds are consistent with an open venous stasis ulcer in a patient with a history of venous stasis, these would be considered qualifying wounds and meets coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of compression stockings have been met. The record show that you have open venous stasis ulcers or a qualifying wound. This means that you do have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan has to pre-approve compression stockings.