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

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT visit are medically necessary. The Plan denied your request. The Plan says the services appear to be for strengthening and endurance not for a skilled therapist.
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 ten (10) additional PT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee is independent in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitting of spectacles (92341) received August 5, 2020.

You asked the Plan to pay for the fitting of spectacles (92341). You say that the enrollee relies on the resident facility to arrange all care. The Plan denied your request. The Plan says routine vision care services must be received through the Plan's network.

Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received through a Plan-participating vision care provider.

We looked at the file and the Plan's rules. The Plan does not offer coverage for vision care services received outside of the Plan's network. Based on this information, we decided that the Plan's rules for coverage of the fitting of spectacles (92341) have not been met. Therefore, we decided that the Plan does not have to pay for the fitting of spectacles (92341) received August 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee underwent spinal surgery on June 21, 2021. The physical therapy evaluation dated June 22, 2021 states she needs maximal assist for rolling and is not safe for edge of bed activity. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on October 29, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing was
not approved by the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the provider must
corroborate the documentation in the beneficiary's medical documentation.
We find that the testing services at issue in this appeal are not supported. The documentation does not show
that the enrollee's treating physician ordered the testing at issue to treat or diagnose a specific medical
condition. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the testing services provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair accessory power seat elevation system
(E2300) and push handles (K0108).
You asked the Plan to pre-approve a power seat elevation system and push handles. You say that the item
should be covered. The Plan denied your request. The Plan says the items are not covered benefits.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a wheelchair accessory power seat elevation system (E2300)
and push handles (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiation Therapy for Proton beam therapy (PBT) (Current Procedural Terminology (CPT) code(s): 77522 x15, 77523 x15, 77525, G6002 x15, 77300 x2, 77301, 77334, 77336 x3, 77263, 77427 x3), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says there is no documentation provided as to why a photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by exceeding an integral dose-based metric associated with toxicity. The Plan states there is no documentation provided that the same or an immediately adjacent area has been previously irradiated, and the dose distribution within the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal tissue. The Plan states the enrollee does not meet criteria as a Group 2 diagnosis at the enrollee is not enrolled in a study, trial, or CED for evidence development.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Proton therapy is not an accepted standard for the treatment of oligometastatic disease or (as is the case for this enrollee) oligoprogressive disease. There are no consensus guidelines or literature provided to support the need for proton therapy in this enrollee. Our physician reviewer found that proton therapy can be considered medically necessary when justified with quantitative dosimetric information that shows a clinically meaningful reduction in radiation dose exposure of normal tissues. In order for toxicity risks to be reduced, there should be a clinically significant reduction in dose to critical structures, with an evidence basis of benefit with dose reduction. Generally, for the treatment of oligometastases or oligoprogression, there is no indication for proton therapy aside from exceptional circumstances, documented with a plausible dosimetric benefit. Stereotactic body radiotherapy (SBRT) or hypofractionated radiotherapy can be considered with non-proton based treatment which would be the standard 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Radiation Therapy for Proton beam therapy (PBT) (Current Procedural Terminology (CPT) code(s): 77522 x15, 77523 x15, 77525, G6002 x15, 77300 x2, 77301, 77334, 77336 x3, 77263, 77427 x3), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999 x 2), the radiographic surgical implant (D6190), the bone graft in conjunction with periradicular surgery (D3428), and the extraction of coronal remnants (D7111) provided from November 6, 2020, to December 2, 2020.
You asked the Plan to pay for the unspecified preventive services, implants, bone grafts, and extractions. You say that you had a severe infection in your mouth in March 2020. You say that the dental offices were closed due to Covid-19 so you could not be seen until months later. You say that you had to have surgery on tooth # 12 and 13. You also say that you would like the Plan to be fair to you. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan also says that the requested services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare coverage, the annual benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999 x 2), the radiographic surgical implant (D6190), the bone graft in conjunction with periradicular surgery (D3428), and the extraction of coronal remnants (D7111) provided from November 6, 2020, to December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with seizures and encephalopathy following a recent stroke. The enrollee remains critically ill. The enrollee continues to receive critical acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on May 13, 2020.
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine testing provided on November 11, 2020.
You asked the Plan to waive the copayment for nuclear medicine testing. You say that you were not informed that there would be a charged after your upfront payment of $40. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 copayment for in-network nuclear medicine testing at an outpatient hospital. You have been asked to pay $250 copayment for nuclear medicine testing. Nuclear medicine testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayment for nuclear medicine testing provided on November 11, 2020.
Your complaint regarding not being told about the cost-share for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genetic testing: Guardant360 (Current Procedural
Terminology (CPT) code 81479) provided to the enrollee on March 9, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the criteria is not met because there is no indication that solid tissue testing, the
preferred method of genetic testing is not possible or is contraindicated (should not be done). The Plan states
the medical records indicate that the enrollee previously had this testing and there is no documented new
growth (of tumors) that may be sufficiently genetically different to require additional genetic testing therefore,
the denial is upheld.

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 laboratory services. Our physician
reviewer found the LCD enumerates the criteria for coverage that state, in relevant part that Guardant360 is
covered only when all of the following conditions are met: Patient is untreated for the cancer being tested or the
patient is not responding to treatment (e.g. progression or new lesions on treatment). In this case, the enrollee
has previously been diagnosed and treated for lung cancer. Guardant360 testing has already been performed
that identified no targetable mutations. The enrollee is currently being treated with dabrafenib and trametinib
for the enrollee's condition. The elements of the coverage rules are not satisfied. The requested service cannot
be recommended.

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 laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for Genetic testing: Guardant360 (Current Procedural Terminology (CPT) code 81479)
provided to the enrollee on March 9, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on January 15, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventative procedure.
The Plan denied your request. The Plan says that the claims were processed correctly and you are being
charged the correct amount.
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 did not provide medical records in the case file substantiating their
decision. Without medical records we cannot determine whether or not the colonoscopy was diagnostic or
preventative. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy provided on
January 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluations (93295, 93296) rendered
by the out of network (OON) provider on April 24, 2020.
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 denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 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 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 interrogation device evaluations (93295, 93296) rendered by the out of network (OON) provider on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits provided on March 25, 2020 and March 24, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visits. You say that you feel you should be reimbursed for these services. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
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 the office visits provided on March 25, 2020 and March 24, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral 
- complete series of radiographic images (D0210) received February 10, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and the intraoral complete series of radiographic images. You say that you were unaware that there was a frequency limitation for the requested services. The Plan denied your request. The Plan says comprehensive oral evaluation are covered at 100% every three years when an in-network provider renders the services. Full mouth or panoramic x-rays are covered one procedure code every five years covered at 100% when an in-network provider renders the services.

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 in excess of those covered under this benefit. The Plan has submitted evidence that you last received the requested services on June 7, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral - complete series of radiographic images (D0210) received February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on
February 5, 2021.
You asked the Plan to pay for the dental service. You say that this service should be covered. You say that you
will seek legal counsel if the service is not overturned. You also say that you were told that the root canal was
approved. The Plan denied your request. The Plan says incomplete endodontic therapy is not listed as a covered
service.
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 incomplete endodontic therapy is
not among those covered under this benefit. The Evidence of Coverage clearly states that any services no listed
are not covered. Therefore, we decided that the Plan does not have to pay for the incomplete endodontic
therapy (D3332) provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit.
You asked the Plan to pre-approve the sensor. You say that you need this type of meter to monitor your blood sugar. You state you previously had this meter but are not able to fill it. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit.