Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that the more therapy the enrollee received, the better it will be for her. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve furniture for a seat lift.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the furniture portion of a seat lift mechanism 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 furniture for a seat lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is needed due from past injuries. 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 orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve proton beam radiation therapy. You say that this is medically necessary. The Plan denied your request. The Plan says there is no benefit of proton beam therapy over intensity-modulated radiation therapy (IMRT).
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 proton beam radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office service. You say that the doctors at this provider know your medical history and what type of procedure you need done. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 office services 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 insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because there is a lack of evidence to support that Vertiflex is as safe and effective as the gold standard of decompression.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of this device. Open laminectomy is the gold standard procedure for spinal stenosis decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex spacer is experimental. More research is needed to show the safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat transforaminal lumbar epidural steroid injection (TFESI).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a lumbar TFESI is covered when specific criteria are 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 services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain with lumbar radiculopathy. He received bilateral L4-L5 transforaminal steroid injections in March of 2020. Magnetic resonance imaging from February of 2020 shows disc degeneration. The progress note dated March of 2021 notes he has tried TENS therapy, physical therapy, physical therapy and is taking over-the-counter ointments and Motrin. The criteria for coverage are met and the repeat injection is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a repeat transforaminal lumbar epidural steroid injection (TFESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 31, 2021.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the enrollee is not safe to discharge based on clinical presentation. The Plan denied your request. The Plan says the denial of continued inpatient psychiatric care is correct, because the enrollee has stabilized as much as possible in an acute inpatient setting and continued care in a non-acute setting is more appropriate.
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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of March 31, 2021. Our physician reviewer found based upon the records provided it is not expected that this enrollee would improve in a reasonable period of time beyond March 31, 2021 as he was not showing any dangerousness to self or others, auditory or visual hallucinations, aggressive behaviors, or acute threats of safety. He is described as preoccupied. It does 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 March 31, 2021. The Plan's denial of continued inpatient psychiatric services appears appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the surgical procedure for isolation of tooth with rubber dam (D3910) provided from November 4, 2020, to November 25, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, the complete series x-ray, and the surgical procedure for isolation of tooth with rubber dam. You say that the services were denied as out of network. You also say that prior authorization is not required. The Plan denied your request. The Plan says comprehensive oral evaluation and complete series x-ray are each covered once every 3 plan years. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that surgical procedure for isolation of tooth with rubber dam is not listed as a covered service.
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, the frequency limit of 1 comprehensive oral evaluation and complete series x-ray each, every 3 plan years have been exceeded. The record shows that the Plan paid for these services that you received on June 25, 2019. Additionally, the surgical procedure for isolation of tooth with rubber dam is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series x-ray (D0210), and the surgical procedure for isolation of tooth with rubber dam (D3910) provided from November 4, 2020, to November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam and Neutron Beam Radiotherapy.
You asked the Plan to pre-approve Proton Beam and Neutron Beam Radiotherapy. You say that the records provided support the need for the requested type of radiation. The Plan denied your request. The Plan says there is no current research showing that the type of cancer the enrollee has, responds better to the requested type of treatment than intensity-modulated radiation therapy.
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 Proton Beam and Neutron Beam Radiotherapy. Our reviewer says that Proton Beam and Neutron Beam Radiotherapy is not considered medically reasonable and necessary in this case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question. Other treatment approaches are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and remains controversial. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Proton Beam and Neutron Beam Radiotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam and Neutron Beam Radiotherapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays provided to the enrollee on June 27, 2020 and billed under code 73610 for claim 820201830005135 (claim A).
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial as the case lacked information specific to the claim. The Plan requested a reopen and provided additional information. The Plan stated that claim A denied because the procedure code billed is not correct or valid for the services billed. The Plan states the claim required the anatomic specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral procedure) to designate the area or part of the body on which the imaging was performed. The Plan provided the claim image that shows the provider has billed this service without the appropriate modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers. In this case, this claim cannot be paid as billed due to the omission of the required modifier to identify the part of the body imaged. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for x-rays provided to the enrollee on June 27, 2020 and billed under code 73610.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-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 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 services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 physician services provided on June 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not insulin-treated. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider
on December 31, 2019.
You asked the Plan to pay for nursing facility care. You say that medical records and proof of timely filing are
attached for retro authorization. The Plan denied your request. The Plan says in-network providers were
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 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 nursing facility care provided by an out-of network
provider on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable oxygen system, oxygen concentrator and nebulizer provided on October 28, 2020.
You asked the Plan to waive the coinsurance for the portable oxygen system, oxygen concentrator and nebulizer. You say that you received a bill, and you want it handled by the Plan. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered benefits from an in-network provider. You have been asked to pay a total of $35.80 for the portable oxygen system, oxygen concentrator and nebulizer.
The portable oxygen system, oxygen concentrator and nebulizer fall within the "Durable Medical Equipment (DME) and Related 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 coinsurance for the portable oxygen system, oxygen concentrator and nebulizer provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition.
You asked the Plan to pre-approve intradialytic parenteral nutrition. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that parenteral nutrition is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intradialytic parenteral nutrition have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition.