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

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.

You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says based upon the clinical notes reviewed, the member does not meet medical necessity guidelines.

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 an additional ten (10) 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 for this condition 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 has been instructed 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 an additional ten (10) PT visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injections.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says the medication falls under Part D coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator device provided on July 15, 2020.
You asked the Plan to pay for neuromuscular stimulator. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item may have been ordered by unsolicited telephone outreach and was not ordered by the enrollee's treating physician.
The Plan must follow Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item, nor does the record show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator device provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), and the prophylaxis (D1110) provided on December 20, 2020.

You asked the Plan to pay the in network rate for the dental services. You say that you went for a normal 6 month cleaning and checkup. You say that this has always been completely covered by your policy. You say that you were never informed that your dentist was no longer in network. You also say that you do not feel obliged to pay these charges. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may have a higher cost share amount. The Plan also says You may be billed by the out of network provider for any amount greater than the payment made by the Plan to the provider.

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 and the services are listed as covered, dental services performed out of network may have a higher cost share amount. Additionally, out of network providers may bill you for the difference between what the Plan paid and what the provider charged. Therefore, we decided that the Plan does not have to pay the in network rate for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), and the prophylaxis (D1110) provided on December 20, 2020.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. 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 congestive heart failure and
cardiogenic shock. Medical problems 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, in 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.

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 pay for infusion supplies (J1559, K0552) provided on October 12, 2020.

You asked the Plan to pay for infusion supplies. You say that these items have always been covered. The Plan denied your request. The Plan says there is not a valid proof of delivery for these items.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket in the file is not specific to the billed date of service and items. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for infusion supplies (J1559, K0552) provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for outpatient therapy services.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says care must be received from a network 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 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 referral out-of-network for outpatient therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.

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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. She had prior genicular RFA in 2017 and 2020 with sustained pain relief. While she has had excellent results in the past, this is considered an experimental/investigational approach which is the subject of on-going clinical trials. Therefore, the request is considered not medically necessary or reasonable.

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 genicular nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopic decompression of the spinal cord (62380).

You asked the Plan to pre-approve an endoscopic decompression of the spinal cord. You say that the requested service is necessary for the enrollee's care. The Plan denied your request. The Plan says the requested procedure is experimental/investigational.

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 an endoscopic decompression of the spinal cord. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain with a herniated disc at L4-L5. The enrollee is taking Morphine, Percocet and Gabapentin for pain. However, the requested procedure is still considered investigational because of a lack of randomized comparative studies.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an endoscopic decompression of the spinal cord have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoscopic decompression of the spinal cord (62380).
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not 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 medically necessary. Our physician reviewer found the enrollee has a medical history of stage IV throat cancer that is in remission after surgery and chemotherapy and radiation. He is living at home with home health services. His medical problems are stable and he has no complex nursing or rehabilitation needs. He 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. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (93306).
You asked the Plan to pre-approve transthoracic echocardiography. You say that this is medically necessary. The Plan denied your request. The Plan says there have not been changes since the previous testing.
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 transthoracic echocardiography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found here is limited information regarding the patient's past cardiac history other than a reported diagnosis of diastolic heart failure. He has no symptoms of chest pain, dyspnea or swelling and no recent admissions to the hospital or intercurrent cardiac events. On exam he has clear lungs, a normal cardiovascular exam and no edema. His blood pressure is well controlled on his current medical regimen. Based on the records provided, there are no clinical indications based on published appropriate use criteria for transthoracic echocardiography 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 transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (93306).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ambulance transportation provided on September 14, 2020.

You asked the Plan to waive the co-payment for ambulance transport. You say that you were told by the fire department and police department that you would not have to pay for this ambulance. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 co-payment for ambulance transport.

You have been asked to pay $225 co-payment for ambulance transport. Ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for ambulance transportation provided on September 14, 2020.

Your complaint regarding receiving inaccurate information 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 29, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 22854 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical
device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws,
flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in
conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary
procedure).

We find that CPT code 22854 is not supported in the medical record. Specifically, there is no documentation of
insertion of intervertebral biomechanical device(s). Based on this information, we decided that Medicare rules
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
the surgical services rendered on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right genicular nerve block.

You asked the Plan to pre-approve right genicular nerve block. You say that this is medically necessary. The Plan denied your request. The Plan says current peer reviewed medical literature lacks well controlled studies to support the use of genicular nerve blocks as the standard of care for the treatment of chronic knee pain.

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 right genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested service is considered an experimental and investigational approach to the treatment of knee osteoarthritis. It is the subject of on-going clinical trials. Therefore, the request is considered 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 right genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve right genicular nerve block.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Barostim Neo device.

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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of heart failure with reduced ejection fraction with left ventricular ejection fraction of 27 percent. She reported only mild shortness of breath, no edema lungs were clear and there were no other signs of congestive heart failure (CHF) on exam. In selected circumstances, Barostim Neo may have a limited role in symptoms improvement in patients who have significant and recurrent symptoms and signs of significant CHF despite full guideline directed therapy. However, the symptoms reported are mild, there are no physical signs of CHF and titration of maximally tolerated doses of guideline directed medical therapy is still being implemented. The device is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Barostim Neo device.