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

We decided that the Plan does not have to pre-approve radiation therapy for the enrollee.
You asked the Plan to pre-approve radiation therapy for knee treatment. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for radiation therapy for treatment-resistant osteoarthritis. The Maximus Physician Reviewer determined that radiation therapy is an accepted standard for osteoarthritis based on reviews from Germany. The Plan requested a reopen and stated that the use of radiation therapy in the treatment of osteoarthritis is not considered an acceptable practice in the United States and is considered investigational therapy. Our Medical Director states the medical records show the enrollee reported temporary relief of her knee pain with elevation and a heating pad. There is no documentation that the enrollee was on medications for osteoarthritis. Our Medical Director has concluded that the Plan is correct in this case. The documentation in the case file is insufficient to demonstrate that the enrollee had treatment-resistant osteoarthritis.
Furthermore, radiation therapy for the treatment of osteoarthritis is not an accepted standard of care in the United States and would be considered investigation/experimental. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy for knee treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Nepro drink, enteral formula, nutritionally complete,
for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins,
fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube,
100 calories (B4154).
You asked the Plan to pre-approve the Nepro drink. You say that you are unable to afford supplements. You
are unable to eat solids and has to consume Nepro. Your provider is unable to prescribe another supplement
because you are diabetic and there's sugar in the other products. The Plan denied your request. The Plan says
supplements to add nutrition in someone with a functioning intestinal tract is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan
does not have to pre-approve the Nepro drink, enteral formula, nutritionally complete, for special metabolic
needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates,
vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories
(B4154).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to waive the copayment for the requested LDCT scan. You say that you were told the LDCT would be no cost to you. The Plan denied your request. The Plan says you did not meet criteria for an LDCT and you were charged the copayment correctly for an outpatient diagnostic test.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. The record shows that you quit smoking tobacco products greater than 15 years ago. Criteria is not met for an LDCT. This means you have a copayment for an Outpatient Diagnostic Test. The Plan charged you $80.90, which is less than your required copayment because the Medicare allowed amount is less. Therefore, we decided that the Plan does not have to waive the copayment for a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a trabeculoplasty by laser surgery (65855).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has open angle glaucoma. The corrected intraocular pressure on pharmacologic treatment is fifteen. The enrollee does not have elevated pressure with treatment. The medical records do not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a trabeculoplasty by laser surgery (65855).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that your current power wheelchair is not functioning properly. The Plan denied your request. The Plan says you do not meet criteria for a new power wheelchair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a power wheelchair. Your current power wheelchair serves the same purpose as the requested power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the contraceptive implant services rendered on October 5, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only. The
rules say that codes with a status indicator of I are not valid for Medicare purposes.
We looked at the file and Medicare rules. The services at issue are a contraceptive implant system for
contraceptive purposes. This is a preventive service that is not covered by Medicare. Furthermore, the
procedure code at issue J7307, has a status indicator of I and is not valid for Medicare purposes. Therefore, we
decided that the Plan does not have to pay for the contraceptive implant services rendered on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says you are not currently on insulin.
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered when the enrollee is on insulin.
There is no evidence of insulin use in the records. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on January 6, 2021.
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 codes 88184 and 88185 are not supported.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the claim for procedure code 88184 (flow cytometry, technical component only, first marker) is a duplicate of a claim previously processed by the Plan.
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 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 88185 is flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker). We find that CPT code 88185 is not supported in the medical record. Specifically, this is an add-on code, and given that the primary procedure code, 88184, is not supported, the add-on code is also not supported. 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 testing services rendered on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular stimulator, electronic shock unit (E0745) for treatment for multiple sclerosis.

You asked the Plan to pre-approve Neuromuscular stimulator. You say that you are not able to do exercises that would help with muscle strength in your legs and this treatment would help with the muscle strengthening and you want to be able to continue to walk. The Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria for the Tens device. A Tens unit for muscle weakness associated with multiple sclerosis does not meet the coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. 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 pre-approve a neuromuscular stimulator, electronic shock unit (E0745) for treatment for multiple sclerosis.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on November 5, 2020.
You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance transport was medically necessary. Our physician reviewer found that in this case, the enrollee's family called emergency medical services (EMS) and upon arrival noted the enrollee had been recently discharged and not acting right. The fire department medical had already assessed the enrollee as a SEPSIS ALERT, possibly COVID. The prudent layperson standard is satisfied. The elements of the coverage criteria are satisfied. The requested service is 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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on November 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that the additional PT visits are medically necessary. The Plan denied your request. The Plan says that there is not much improvement in function despite PT.
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 twelve (12) 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 and caregiver have had continued education and safety instruction. 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 twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on September 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit has been reached.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $10 copayment for up to 30 visits each calendar year for routine chiropractic services. Review of the file shows that routine chiropractic services were provided to the enrollee on September 8, 2020. The records show that the enrollee was provided 30 routine visits prior to the visit in question. The Plan paid for 30 routine visits. This means that the requested visit exceeds the benefit limit. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided to the enrollee on September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a debridement (11042) provided February 15, 2021.
You asked the Plan to pay for the debridement. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 11042 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the debridement have not been met. Therefore, we decided that the Plan does not have to pay for a debridement (11042) provided February 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 14, 2021.
You asked the Plan to waive the copayment for emergency care. You say that the emergency room did nothing for you and you ended up leaving. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 a $90 copayment for emergency care. The medical records show that you received emergency care on March 14, 2021. Therefore, you are responsible to pay the allowed amount of $77.70, which is less than the $90 copayment.
You have been asked to pay $77.70 for emergency care. Emergency care falls within the emergency care 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 emergency care provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 months Continues Airway Pressure Device (CPAP) and Humidifier (E0601 and E0562).
You asked the Plan to pre-approve the CPAP and humidifier. You say that you require ten months of the device. The Plan denied your request. The Plan says the plan said they will approve three months per the Medicare rules, but not the ten requested.
The Plan must follow Medicare rules. Medicare rules say that no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document that the enrollee is benefiting from PAP therapy. The Plan will approve the first three months (90 days) until the treating practitioner can determine if the CPAP is benefitting the enrollee. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 months Continues Airway Pressure Device (CPAP) and Humidifier (E0601 and E0562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system.
You asked the Plan to pre-approve the Volara system. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a benefit of Medicare or the Plan.
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 Volara system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is not sufficient clinical evidence to demonstrate that oscillation and lung expansion (OLE) therapy positively impacts outcomes in patients with primary ciliary dyskinesia, bronchiectasis, pulmonary vein thrombosis, and cystic fibrosis. 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 Volara system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on March 23, 2021.
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 code 70450 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT scan head/brain) and 70496 (CT angiography, head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496.
Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional OT visits from January 28, 2021, through December 31, 2021.
You asked the Plan to pre-approve twenty (20) additional OT visits. You say that the additional OT is medically necessary. The Plan denied your request.
The Plan says there is no clinical evidence to support the medical necessity of this examination or that the member meets Medicare criteria for continued OT therapy services.
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 twenty (20) additional OT 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 has been lives in a long-term care facility and receives assist from staff and has had therapy education. 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 twenty (20) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional OT visits from January 28, 2021, through December 31, 2021.