Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction by neurolytic agent, genicular nerve branches
including imaging guidance (64624) provided on December 11, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service provided was 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 pay for this service. Our reviewer says that the
service provided is not considered medically reasonable and necessary in this case. Our physician reviewer
found that this service is considered an experimental/investigational approach and is the subject of on-going
clinical trials.

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 pay for the destruction by neurolytic agent, genicular nerve branches including imaging guidance (64624) provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.

You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee is not taking insulin and does not require frequent insulin adjustment.

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 a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve chiropractic services. You say that you would like these services to be
provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network
providers available for these services.

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
chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an out-of-network provider.

You asked the Plan to pre-approve a consultation. You say that the in-network doctor does not specialize in their type of cancer. You say that a second opinion with an out-of-network provider is necessary. 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 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 a consultation with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile gloves.

You asked the Plan to pay for the sterile gloves. You say that you would like reconsideration because you need these gloves to take care of the member. The Plan denied your request. The Plan says the gloves are not a Medicare covered benefit

The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is equipment which can withstand repeated use.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sterile gloves have not been met. Specifically, the requested gloves are not a Medicare covered benefit because they do not meet Medicare's definition of durable medical equipment. Therefore, we decided that the Plan does not have to pay for the sterile gloves.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayments for eye exams or vision services provided between February 27, 2019, and May 27, 2020.
You asked the Plan to waive the copayments for the eye exams. You say that you received a letter from the Plan stating that you did not have to pay copayments for eye exams. The Plan denied your request. The Plan says that they have corrected some copayments in 2020 and provided reimbursement for the services received after June 1, 2020 due to the Plan's pandemic press release. However, the remaining claims submitted for review were processed correctly and you are responsible for those costs.
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 rules also say that a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The information forwarded to us did not include complete information on the claims submitted. The Explanation of Benefits (EOB) listed each service on the date in question as a non-covered item or service (A9270). The only amounts listed with these items were the copayment amounts. The Plan referred to these services as covered eye exams and the amounts at issue as copayments. It is unclear from the file what types of eye exams were provided on the dates in question. We requested additional information from the Plan, but it was not received before the due date. The Plan says that Medicare-covered exams to diagnose and treat diseases or conditions of the eye require either a $0 or a $30-$35 copayment. We cannot verify that the services provided are not eligible for the $0 copayment listed by the Plan.
Therefore, we decided that the Plan has to waive the copayments for eye exams or vision services provided between February 27, 2019, and May 27, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided on August 25, 2020.

You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We asked our coder 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 nerve conduction studies and needle electromyography. Our reviewer says that CPT code 95909 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document that a nerve conduction study of 5-6 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95909. Our reviewer found CPT code 95885 does not meet criteria for billing or reimbursement consideration.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network cardiology services.

You asked the Plan to pre-approve the cardiology services. You say that this provider has been their doctor for 15 to 20 and performed three surgeries. You say that due to his age they want to continue seeing the member. The Plan denied your request. The Plan says the requested cardiology 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 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 pre-approve out-of-network cardiology services.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has no complex medical needs that require intensive rehab.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical decompression and fusion. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
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 IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 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 while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive inpatient rehabilitation services. Medically necessary care can be provided at a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic for tooth 11 (D2740).

You asked the Plan to pre-approve a porcelain/ceramic crown. You say that the service is medically necessary and should be covered. The Plan denied your request. The Plan says this service is not listed as a covered under the enrollee's dental benefits.

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 crown - porcelain/ceramic for tooth 11 (D2740).
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 care. You say that SNF services are medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. Finally, this beneficiary 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 SNF care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the admission is not deemed medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Medical problems are stable. There are no 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips because you have cancer treatment every three weeks and no other way to get there. Plan denied your request. The Plan says only 24 one-way trips are covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided in a nursing home on December 9, 2020.
You asked the Plan to pay for the medical services. You say that this provider is able to bill Medicare and has received Medicare payment for services. The Plan denied your request. The Plan says that the services are not covered as the provider is not a Medicare qualified mental health care professional.
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 argues this denial is correct because the provider at issue is not a Medicare qualified mental health professional. However, Maximus was able to confirm that this provider is listed as currently enrolled in Medicare Base Provider Enrollment File. We were also able to verify that this provider has a current nurse practitioner license in the State of California. It is noted that the taxonomy associated with the National Provider Identification (NPI) number is listed as "Student in an Organized Health Care Education/Training Program." In spite of this, the provider is currently enrolled in Medicare and licensed in the state of practice. We find there is not sufficient evidence to support that this provider is not able to receive Medicare payment for these services. Therefore, we decided that the Plan has to pay for the medical services provided in a nursing home on December 9, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee has not had a qualifying trial of conservative therapy or use of a basic E0651 compression device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).