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

We decided that the Plan does not have to pre-approve an E0784 External Ambulatory Infusion Pump for Insulin.

You asked the Plan to pre-approve n E0784 External Ambulatory Infusion Pump for Insulin. You say that this device is medically necessary. 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 coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an external ambulatory insulin infusion pump. The Maximus Physician Reviewer determined this equipment could be beneficial for your use. The Plan argues that there was no documentation of a fasting C-peptide or of a beta cell autoantibody positive lab in the medical records. The Plan is correct in this case. The documentation is insufficient to demonstrate that all of the coverage criteria established by NCD 280.14 have been met in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of n E0784 External Ambulatory Infusion Pump for Insulin have not been met. Therefore, we decided that the Plan does not have to pre-approve an E0784 External Ambulatory Infusion Pump for Insulin.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (CPT code A9270) provided from
January 15, 2021, through January 16, 2021.
You asked the Plan to pay for self-administered drugs. You say that the self-administered medications were
necessary for the procedure you underwent. The Plan denied your request. The Plan says this code was billed
with A9270, which is non-covered item or service. The Plan states A9270 is not paid by Medicare when
submitted on outpatient claims.
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 pay for self-administered drugs (CPT
code A9270) provided from January 15, 2021, through January 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 18, 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 submitted records do not support the billing of code 99285.
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 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity. 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 these services. Our reviewer says that the submitted records do not support the billing of code 99285. Our physician reviewer found the enrollee received emergency services on July 18, 2020. The enrollee presented after a fall form standing position with injury to hand, knee and foot. There was no loss of consciousness. The documentation provided does not support the presence of an immediately life threatening condition to support the billing of code 99285. 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 not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on July 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 23, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a liver transplant evaluation for the enrollee.

You asked the Plan to pre-approve the evaluation. You say that this is medically necessary. The Plan denied
your request. The Plan says that there is a MELD score of 9.

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 evaluation. Our reviewer says that
the requested evaluation is considered medically reasonable and necessary in this case. Our physician reviewer
found you have cirrhosis nonalcoholic steatohepatitis with a MELD score of 9. You have portal hypertension
twice requiring banding of esophageal varices as well as severe thrombocytopenia. You also require repair of
an umbilical hernia that will place you at risk for acute decompensation. The documentation provided supports
the medical necessity and reasonableness of the requested service.

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 evaluation have been met. Therefore, we decided that the Plan has to preapprove
a liver transplant evaluation for the enrollee.

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 waive the co-payment for an eye exam provided by a participating provider on February 17, 2021.

You asked the Plan to waive the co-payment for an eye exam. You say that you thought that this would be covered. You say that you have never had a co-payment for this before. The Plan denied your request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for vision care/Medicare-covered eye exam.

You have been asked to pay a $35 co-payment for an eye exam. When a Medicare-covered eye exam is provided to treat diseases or conditions of the eye, a $35 co-payment is applied; therefore, the correct co-payment has been applied. An eye exam falls within the vision care/Medicare-covered eye exam 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 co-payment for an eye exam provided by a participating provider on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from June 3, 2021, forward.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 mental health care. Our physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 3, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and compliant. 

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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from June 3, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the lower left and lower right quadrants.

You asked the Plan to pre-approve the periodontal scaling and root planing. You say that these services are necessary for these quadrants. The Plan denied your request. The Plan says that this service, as coded and requested, is inappropriate for this enrollee as there are fewer than four teeth in the requested quadrants.

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. The Plan covers the periodontal scaling and root planing when the services are medically necessary and reasonable.

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 periodontal scaling and root planing. Our reviewer says that periodontal scaling and root planing for four or more teeth per quadrant is medically necessary and appropriate as requested. Our physician reviewer found that the dentition in the lower left and right quadrants is comprised of implants along with natural teeth. Implants must be treated as teeth since they are susceptible to the same periodontal disease as natural teeth. The periodontal charting indicates that both the natural teeth and implants have sufficient periodontal pockets for treatment. The combination of implants and natural teeth comprise the minimum of four teeth per quadrant and the charting of the periodontal pockets indicate the need for the treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the lower left and lower right quadrants.

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 fully pay for the emergency dental treatment provided on January 6, 2021.
You asked the Plan to fully pay for the emergency dental treatment. You say that the dentist couldn't find the problem and they got paid. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 Plan is only obligated to pay 50% of the cost for comprehensive dental services. Therefore, we decided that the Plan does not have to fully pay for the emergency dental treatment provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert system.
You asked the Plan to pre-approve an alert system. You say that this is necessary. The Plan denied your
request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that emergency communication systems are not
covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not
provide coverage for an alert system have not been met. Therefore, we decided that the Plan does not have to
pre-approve an alert system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 17, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has hypertension and hypercholesterolemia. The records provided do not provide sufficient information to determine the medical necessity and reasonableness of the requested service.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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. Your medical conditions are stable. You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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. Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from an 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lower extremity for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says that there are no x-rays of the right knee.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee had trauma
and had bilateral physical findings of the knees on 3/3/21. There are x-rays of the left knee, but not of the right
knee. While radiographs of the knee are routinely useful the fact of the matter is the enrollee still has symptoms
referable to the right knee three months after the trauma. Even if x-rays were to turn out normal, the requested
MRI of the right knee would still be necessary due to the history of trauma and three months duration of
symptoms. MRI would be a much more sensitive means with which to evaluate for bone and soft tissue injury
than plain radiographs.
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
MRI of the lower extremity for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a treatment regimen combination of Keytruda (Pembrolizumab), Cisplatin, and Irinotecan, with Palonosetron, Dexamethasone, and Fosaprepitant for the enrollee.

You asked the Plan to pre-approve this treatment. You say that this treatment 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 coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda (Pembrolizumab), Cisplatin, and Irinotecan, with Palonosetron, Dexamethasone, and Fosaprepitant. The Maximus Physician Reviewer determined that, although the requested drugs are not approved by the FDA for the enrollee's diagnosis, the use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.

The Plan requested a reopen and argues that there is no established evidence to support the use of Keytruda (pembrolizumab)/cisplatin/irinotecan in metastatic squamous cell esophageal cancer. The medical records show the enrollee is a 73-year-old man with a diagnosis of poorly differentiated squamous cell carcinoma of the esophagus, metastatic to the lungs and liver.

Our Medical Director has concluded that the Plan is correct in this case. There is insufficient support in the medical literature for the use of Keytruda (Pembrolizumab), Cisplatin, and Irinotecan in the setting of metastatic squamous cell esophageal cancer. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve a treatment combination of Keytruda (Pembrolizumab), Cisplatin, and Irinotecan, with Palonosetron, Dexamethasone, and Fosaprepitant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided out of network from September 15, 2020, to October 20, 2020.
You asked the Plan to pay for acupuncture. You say that this treatment should be covered by the Plan. The Plan denied your request. The Plan says the provider did not submit Medical records to show this treatment was rendered by a valid licensed physician.
Maximus overturned the denial for lack of information to support the denial. The Plan requested a reopen and provided additional documentation regarding their requests for medical records from your provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare offers limited coverage for acupuncture treatments. The Plan only covers acupuncture provided by a licensed physician. You received treatment from an out of network provider who did not respond the Plans requests for medical records or provide verification that this treatment was rendered by a licensed professional. Therefore, we decided that the Plan does not have to pay for acupuncture services provided out of network from September 15, 2020, to October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right eyelid surgery.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says eyelid surgery can be approved for the left eye.

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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support a margin reflex distance of the right eye of 2.0 mm or less. The photographs do not show the right eyelid obstructing the pupil. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right eyelid surgery.