Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the enrollee is only able to stand for 15-20 minutes with support.The Plan denied your request. The Plan says there are in-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-approvephysical therapy 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 pay for the medical services provided to the enrollee by an out-of-network provider on June 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on June 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the plan has already approved twelve visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition at this time beyond what was approved by the health plan. The enrollee has had extensive therapy for this condition and without completion of the already authorized therapy it is not clear that the enrollee requires the additional requested therapy with the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been authorized additional sessions to review an independent exercise program. The specialized skill, knowledge
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration at this time. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve fourteen additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on May 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 the physician's services provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns (D2750) for teeth # 23, 24, 25, and 26.You asked the Plan to pre-approvethe crowns. You say that the crowns are necessary.The Plan denied your request. The Plan says the teeth do not appear to have significant breakdown. The Plan also says the services are not meet the criteria for coverage.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 crowns 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 crowns. Our reviewer says that the crowns for teeth # 23, 24, 25 and 26 are not medically necessary. Our physician reviewer found the teeth had been noted as having an old filling on # 23 that repeatedly has been falling out, a lost restoration on # 24 incisal with mesial and distal decay, # 25 mesial decay, and # 26 with leakage under mesial incisal distal restoration.  The reviewer found that in this instance, none of the involved teeth have sufficient damage of enough surfaces to qualify for a crown restoration under the Plan criteria. Therefore,the reviewer found the requested crowns are not medically reasonable or necessary.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 crowns have not been met.Therefore, we decided that the Plan does not have to pre-approvecrowns (D2750) for teeth # 23, 24, 25, and 26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.

You asked the Plan to pay fo the services. The Plan denied your request. The Plan says the services were not authorized.

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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH).You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, such as a skilled nursing facility.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 tocarefully 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 you appear to be stabilizing, but require additional short term acute care services to help stabilization, which can safely be administered in the current setting. You do not require services at the LTACH that are not already available at the current setting. Transfer to a lower level of care may be considered when treatment has completed.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.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs SNF care. The Plan
denied your request. The Plan says the criteria for admission to a SNF 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 above 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 the SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found although there are identifiable
skilled therapy service needs, there are no identifiable skilled nursing service needs. Furthermore, the
beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says that care can be provided in the current inpatient hospital.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not substantiated their denial. The plan has provided an incomplete case file to MAXIMUS, without medical records, claims, denial letters, or any information to help MAXIMUS review their decision to deny this admission. Therefore, we decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Advanced prosthetic leg to be provided by the out-of-
network provider.
You asked the Plan to pre-approve an Advanced prosthetic leg. The Plan denied your request. The Plan says
your contract with the Plan says that you must receive care from in-network providers with the exception of
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be
provided with an in-network provider, which requires prior authorization from the plan
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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an Advanced
prosthetic leg to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's clinical condition meets the full inpatient acute rehab criteria and that the lower level of care in a skilled nursing facility cannot provide the approach needed and would only serve to teach the enrollee and family compensatory skills rather than useful return of function.The Plan denied your request. The Plan says rules for IRF care have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medicaland rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy,and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveIRF admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea BioimpedanceSpectroscopy.You asked the Plan to pre-approvea Bioimpedance Spectroscopy. You say that the requested Bioimpedance Spectroscopy is medically necessary.The Plan denied your request. The Plan says the requested Bioimpedance Spectroscopy 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 a Bioimpedance Spectroscopy. Our reviewer says that the requested Bioimpedance Spectroscopy is not medically necessary. Our physician reviewer found the enrollee was diagnosed with breast cancer and underwent a right lumpectomy, lymph node removal, radiation and chemotherapy. The Oncology Times, June 20, 2019, issue 12, showed no statistically significant difference in outcome with use of Bioimpedance Spectroscopy to detect subclinical breast cancer related to lymhedema. The request is not medically necessary at this time.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 Bioimpedance Spectroscopy have not been met.Therefore, we decided that the Plan does not have to pre-approvea Bioimpedance Spectroscopy.
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically 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 admission to a LTACH is not medically necessary. Our physician reviewer found long term
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing
care needs include intermittent BiPAP, oxygen supplementation, nebulizer treatments, surveillance laboratory
studies, and therapy services.
The documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee at this time.
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. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex device.You asked the Plan to pre-approvea Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Ourreviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with narrowing (stenosis) of the back. The spacer being requested is experimental. More research is needed to show safety and efficacy. At this time, the requested Vertiflex 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 a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on May 29, 2020.
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says you need to bill this claim to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. The service
should be billed to Original Medicare. Therefore, we decided that the Plan does not have to pay for the
ambulance service provided on May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea pneumatic compression device (E0651, E0667) from an out-of-network provider for the enrollee.You asked the Planto pre-approvethe device. You say that the enrollee has tried and failed other devices that are supplied by the network providers.The Plandenied your request. The Plansaysthis device is to be provided by an out-of-network provider.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 there is nothing specific about this brand that would indicate it over ones provided by network providers. The pneumatic compression device (E0651, E0667) that the health plan has agreed to cover from the in-network provider appears adequate to treat 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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea pneumatic compression device (E0651, E0667) from an out-of-network provider for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurostimulators (63650).
You asked the Plan to pre-approve neurostimulators. 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 follows Medicare rules. Medicare rules say that dorsal column stimulators are covered under certain circumstances. 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 neurostimulators. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence based indication for a Spinal Cord Stimulation (SCS) trial and also there is no documentation of trials with multiple other medications for diabetic peripheral neuropathy. The request is not medically reasonable or 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 neurostimulators have not been met. Therefore, we decided that the Plan does not have to pre-approve neurostimulators (63650).