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

We decided that the Plan does not have to pay for cataract surgery provided by an out-of-network provider on October 19, 2020.You asked the Plan to pay for the cataract surgery. You say that the patient was informed they could go out of state for services from July to December.The Plan denied your request. The Plan says in-network providers were available to provide the service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for cataract surgery provided by an out-of-network provider on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lumbar facet joint radiofrequency ablation procedures.

You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635LT), and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636LT). You say that the enrollee needs these procedures for relief of severed bilateral low back pain. The Plan denied your request. The Plan says criteria is not met for the facet joint interventions.

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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635LT), and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636LT). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request does not meet the requirement that the RFA produce 50% pain relief for at least 6 months. This has not been met. Therefore, the request is deemed 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635LT), and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636LT) have not been met. Therefore, we decided that the Plan does not have to pre-approve left lumbar facet joint radiofrequency ablation procedures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve silicone bandages.

You asked the Plan to pre-approve silicone bandages. You say that you need a supply of these bandages because you cannot use regular bandages. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that surgical dressings are covered when a qualifying wound is present. 

We looked at the file and Medicare rules. The records do not show that you have a qualifying wound. Based on this information, we decided that Medicare rules for coverage of silicone bandages have not been met. Therefore, we decided that the Plan does not have to pre-approve silicone bandages.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 28, 2020 and billed under code 61645.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial stating these physician services can be paid separately from the facility claim. The Plan requested a reopen and provided additional explanation stating that the claim was not submitted with the required -26 modifier.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required, the appropriate modifiers. Review of the claim shows code 61645 was not submitted with the required modifier. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on February 28, 2020 and billed under code 61645.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power scooter.You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary.The Plan denied your request. The Plan says there is insufficient documentation to support the power scooter. An evaluation has been approved instead.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file has insufficient documentation to show that your condition cannot be improved by a walker, cane or manual wheelchair, and that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a new power scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pharmacogenetic testing provided on August 3, 2020.You asked the Plan to pay for the molecular pharmacogenetic testing. You say that the Plan should pay this claim.The Plan denied your request. The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.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 molecular pharmacogenetic testing. Our reviewer says that the testing is not considered medically reasonable and necessary in this case. Our physician reviewer found this type of testing has not been shown in current literature to improve clinical outcomes compared to the standard of care. There were no exceptions described in the provided records. Therefore, the criteria have not been met.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 molecular pharmacogenetic testing have not been met.Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental pneumatic appliance (E0668) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are in-network providers available to the enrollee that can provide the items being requested.
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 pneumatic compressor (E0651) and segmental pneumatic appliance (E0668) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.

You asked the Plan to pre-approve a motorized scooter. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you do not meet Medicare criteria.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker, cane or manual wheelchair and no records have been provided to show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the eyeglass lenses, frames, and the fitting of the eyeglasses (V2020, V2100, 92341) provided on January 14, 2021. We also decided that the Plan does not have to pay for the cost of the services that exceed the $250 allowance.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the enrollee has exhausted the allowable benefit for these services.

We decided that the Plan has to pay for the eyeglass lenses, frames, and the fitting of the eyeglasses (V2020, V2100, 92341). The Plan contract states that there is a $250 allowance toward the enrollee's purchase of eyeglass frames each year. The record does not show that the Plan has issued any payment for eyeglass frames for this calendar year. Additionally, standard lenses are covered in full. Therefore, we decided that the Plan has to pay for the eyeglass lenses, frames, and the fitting of the eyeglasses provided on January 14, 2021.

We also decided that the Plan does not have to pay any costs that exceed the $250 allowance. As noted above, the Plan's routine eyewear benefit is limited to $250. This means that the Plan is not required to pay more than this amount toward the eyewear. Therefore, we decided that the Plan does not have to pay any costs that exceed the $250 allowance.

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 pre-approve use of platelet rich plasma (PRP).

You asked the Plan to pre-approve platelet rich plasma (PRP). You say that you previously had this procedure and it worked, and knee replacement would be almost an impossibility for you. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this does not fall within Medicare's established coverage for PRP for chronic non-healing diabetic, venous, or pressure wounds and is considered experimental/investigational for all other indications.

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 platelet rich plasma (PRP). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical rational for this use of a PRP injection. PRP is considered experimental/investigational for all indications including chronic non-healing wounds, epicondylitis, plantar fasciitis, Dupuytren's contracture, bone healing and fusion, and sinus surgery.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of platelet rich plasma (PRP) have not been met. Therefore, we decided that the Plan does not have to pre-approve use of platelet rich plasma (PRP).
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of 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 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 infection of the lower leg and had a below the knee amputation.

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: 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 IRF care. The Plan denied your request. The Plan says the guidelines for coverage of 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 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 groin pain and was treated for obstructive pyelonephritis. 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 an alert or alarm device (A9280).

You asked the Plan to pre-approve this item. You say that an alert device 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 must follow Medicare rules. Medicare rules say that alert systems are not covered because they are emergency communication systems that do not serve a diagnostic or therapeutic purpose. 

While an alert system 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 an alert or alarm device (A9280).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve pathology services (88325, 88323, 88321, 88342).

You asked the Plan to pre-approve the pathology services. You say that the pathology readings are medically necessary for a scheduled surgical procedure. The Plan denied your request. The Plan says that the service is not covered.

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's decision letter does not explain the reason for the denial. The background data form provided by the plan indicates that the provider is a contract provider. No criteria or rationale was provided to support denying the service as not medically necessary. Therefore, we decided that the Plan has to pre-approve pathology services (88325, 88323, 88321, 88342).

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: 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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.

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 surgical repair of a hip fracture after a fall. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71046) provided on January 29, 2021.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network service was not pre-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 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 an x-ray (71046) provided on January 29, 2021.