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

We decided that the Plan does not have to pre-approve the Vertiflex device.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains 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 the device have not been met.Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261).
You asked the Plan to pre-approve a CT colonography. You say that the services are medically necessary. The Plan denied your request. The Plan says Medicare does not cover this study for the purpose of screening you for disease in your colon or rectum.
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 CT colonography. Our reviewer says that the service is not medically necessary. Our physician reviewer found that there were no lab reports, findings on physical exam or CT results recently to provide a contraindication to direct colonoscopy for the purpose of cancer screening. The patient has declined any invasive procedure despite having been informed of the limitations of CT colonography versus direct colonoscopy. The Centers for Medicare and Medicaid Services (CMS) only allows for CT colonography screening if the patient cannot safely undergo direct colonoscopy or if same was incomplete upon recent attempt. As the patient does not satisfy these exceptions the CMS criteria for medical necessity of this test has not been established.
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 CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve implantation of the BaroStim Neo carotid stimulation device.
You asked the Plan to pre-approve the BaroStim Neo procedure. You say that the enrollee has met the FDA indications for the use of this device. There is ample evidence that this would be helpful in managing the enrollee's symptoms. The Plan denied your request. The Plan says that there are current only small initial trials for the use of this system. It is not currently proven effective or endorsed in current guidelines for the treatment of heart failure.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 BaroStim Neo procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Barostim Neo carotid stimulation device implantation is a newer therapy which has shorter term randomized data to support its use in improving quality of life and 6-minute walk capacity in patients who have persistent and significant symptoms of congestive heart failure (CHF) despite being treated with full guideline directed medical therapy. The patient in question has heart failure with reduced ejection fraction (EF), a brain natriuretic peptide (BNP) level which is within the indicated range for use of the device, is not a candidate for cardiac resynchronization therapy, and is on full guideline directed CHF medications and remains with NYHA Class III symptoms despite good medical therapy. Barostim Neo has a role in patients like this who have significant recurrent symptoms and signs of significant CHF despite full guideline directed therapy. This patient has both the FDA approved indications for the device and is similar to patients who benefited with both symptomatic and exercise tolerance improvement in the randomized clinical trial of this device. Although a new technology, the current data is sufficient for FDA approval and clinical use, with some favorable cost effectiveness data available as well, especially where maximal medical therapy has failed to control symptoms, such as with this patient. Therefore, it is found that the patient meets the medical necessity criteria for the use of this 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 the BaroStim Neo procedure have been met. Therefore, we decided that the Plan has to pre-approve implantation of the BaroStim Neo carotid stimulation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from July 31, 2020 to August 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that SNFs billing on Type of Bill (TOB) 21X and rural hospital (non-CAH) swing-bed providers billing on TOB 18X (subject to SNF PPS) must be billed with a PDPM revenue code.
We looked at the file and Medicare rules. The file shows that the services were not billed with a valid PDPM revenue code. 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 pay for the services rendered from July 31, 2020 to August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia (J0717).
You asked the Plan to pre-approve Cimzia. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Cimzia. Our reviewer says that the requested use of Cimzia is not supported in this case. Our physician reviewer found Cimzia is not FDA-approved for member's condition. The requested off-label use is not supported by the manufacturer's web site or by the drug compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cimzia have not been met. Therefore, we decided that the Plan does not have to pre-approve Cimzia (J0717).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift (E1399).

You asked the Plan to pre-approve a stair lift. You say that a stair lift is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.

While a stair lift may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift (E1399).
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 clinical documentation provided supports the need for care in an IRF. The Plan denied your request. The Plan says the enrollee does not need surgical intervention and has been discharged to home with home health services. The Plan says that the enrollee does not meet the criteria for IRF care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbar degenerative disc disease. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor.
You asked the Plan to pre-approve the FreeStyle Libre Continuous Glucose Monitor. You say that you would like reconsideration because you have been using this equipment for 2+ years and it is very helpful as your fingers are sore and you are able to check your blood sugar at any time. The Plan denied your request. The Plan says the record does not show that you use insulin or an insulin pump.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $75 copayments charged for emergency room services provided on September 18, 2020 and September 20, 2020.
You asked the Plan to waive these copayments. You say that you do not believe you owe both copayments. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement. Maximus partially overturned the Plan's denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language.
The Plan is correct in this case. 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 $75 copayment for each Medicare covered emergency room visit. You had two separate and distinct emergency room visits on two separate days. 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 $75 copayments charged for emergency room services provided on September 18, 2020 and September 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor and related supplies provided on December 8, 2020.
You asked the Plan to pay for the provided services. You say that the diagnosis is valid and billable. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the provided services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor and related supplies provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because you will have to use compression stockings for the rest of your life to prevent blood clots. The Plan denied your request. The Plan says gradient compression stockings are non-covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6534 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90791) provided on September 15, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were 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 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90791) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045-26) provided August 31, 2020.You asked the Plan to pay fora chest x-ray. You say that this is not a duplicate claim.The Plan denied your request. The Plan says this service was previously paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 71045-26is not supported for payment. Specifically, the file shows that another provider submitted a claim for this same procedure/date of service/enrollee. The Plan indicates that this service has been paid. The file did not contain medical records to show that a second chest x-ray was medically necessary or justified.Based on this information, we decided that Medicare rules for coverage of a chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045-26) provided August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a repair of dura procedure (61618) performed on December 10, 2020.

You asked the Plan to pay for a repair of dura. You say that the procedure at issue was billed correctly. The Plan denied your request. The Plan says the procedure at issue is 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 61618 is "Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts)."

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 a repair of dura. Our reviewer says that the service at issue is not supported by the available medical record. Our physician reviewer found that the enrollee received services on December 10, 2020, for CPT code 61618. The submitted operative report does not include enough documentation to confirm a secondary repair of dura for cerebrospinal fluid leak was performed. The operative report documents that "The dura was closed basically completely secondarily with a Cygnus allograft reinforced with Adherus dural sealant." Documentation is not clear to confirm procedure was performed.

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 repair of dura have not been met. Therefore, we decided that the Plan does not have to pay for a repair of dura procedure (61618) performed on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant (D7311).You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's dental policy.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 requested service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve an alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Freestyle Libre 14-day reader for the enrollee the Freestyle Libre 14-day reader for the enrollee.
You asked the Plan to provide coverage for the Freestyle Libre 14-day reader for the enrollee this device. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Medicare coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees when all six of the required criteria are met. Based on the medical records provided, the enrollee does not meet all of the required criteria for coverage
of this device. Therefore, we decided that the Plan does not have to provide coverage for the Freestyle Libre 14-day reader for the enrollee the Freestyle Libre 14-day reader for the enrollee.