Persius/hicric huggingface dataset:
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 it is felt that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of care.

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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis and a urinary tract infection. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Irbesartan tab 150mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D or separate pharmacy benefit.

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 Irbesartan tab 150mg for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95870 and 95869 and the short-latency somatosensory evoked potential study coded 95938 provided on October 22, 2020.

You asked the Plan to pay for the needle electromyography services and the short-latency somatosensory evoked potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 95870, 95938, and 95869 are not supported in the medical record. Specifically, the billed place of service 15 (mobile unit) is not supported. The documentation submitted indicates that the enrollee received services in a facility setting. Based on this information, we decided that Medicare rules for coverage of the needle electromyography services and the short-latency somatosensory evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 95870 and 95869 and the short-latency somatosensory evoked potential study coded 95938 provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (CPT code E0676).

You asked the Plan to pre-approve a pneumatic compression device. You say that the DME is necessary. The Plan denied your request. The Plan says the item is not a covered benefit under Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (CPT code E0676).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single
level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.

You asked the Plan to pre-approve the services. You say that in mid-May magnetic resonance imaging was
ordered and revealed indeed a change in the position of the Minuteman device with resultant impingement and
flattening of the left L4 nerve root. You state despite three (3) months of conservative treatment being
unsuccessful the pain due to impingement on the nerve root continued. You state due to the displacement of the
device the levels have become unstable and the corrective replacement of the device be approved under the
secondary code of T84.226D and the second level of the L5-S1 be approved for stability of the enrollee's
lumbar spine. The Plan denied your request. The Plan says the services are considered experimental and
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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found spinal instability has not been demonstrated. The enrollee had a Minuteman device placed that has subsided. Fusion is not needed. Hardware removal and decompression is a better option. Criteria for fusion not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.
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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. At the time of the request, the enrollee's
status is unstable. The enrollee's respiratory status is not stable, requiring HFNC, and the proBNP remains
elevated. The enrollee does not require services at the LTACH that are not available at the acute care hospital
where the enrollee 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
March 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 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 services provided by an out-of-network provider on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has been suffering from this lumbar spinal stenosis for far too long. The Plan denied your request. The Plan says the available evidence is not clear if this device would help or harm the enrollee in the long term.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on November 28, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on November 28, 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 enrollee would benefit from ongoing care in the LTACH setting. The Plan denied your request. The Plan says the current facility is able to meet the enrollee's needs.

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 there is no documentation provided necessitating admission to a LTACH. 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.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortic aneurysm screening you had on January
8, 2021.

You asked the Plan to pay for the screening. The Plan denied your request. The Plan says this exceeds the
benefit limit.

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 there is a $0
copayment for a one-time abdominal aortic aneurysm screening.

Review of the file shows that you had an abdominal aortic aneurysm screening on January 8, 2021. The records
also show that you had a covered abdominal aortic aneurysm screening on September 17, 2019. As this service
is only covered once, the requested screening exceeds the benefit limit. This means that you have been asked to
pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have
to pay for the abdominal aortic aneurysm screening you had on January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the preferred viscosupplements are Orthovisc and Monovisc and do not require authorization.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed one of the plan's preferred viscosupplemental treatment such as Orthovisc or Monovisc. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gel-One is not approved as step 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the diabetic testing supplies provided on March 19, 2021.

You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the items rendered are not payable.

The Plan must follow Medicare rules. Medicare rules say that no more than 1 unit of service (UOS) of HCPCS code K0553 is billable per thirty (30) days. 

We looked at the file and Medicare rules. Review of the file shows that diabetic testing supplies were provided on March 19, 2021. They were previously provided on February 17, 2021. This means 30 days had passed since previously providing the diabetic testing supplies. These supplies are billable once every 30 days. Based on this information, we decided that Medicare rules for coverage of the diabetic testing supplies have been met. Therefore, we decided that the Plan has to pay for the diabetic testing supplies provided on March 19, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services provided by an out-of-network provider on September 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans
denial based on the records provided at the time of the appeal. The Plan requested a reopen and provided
additional medical records for review.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for SNF services.
The Maximus Physician Reviewer determined that the enrollee qualified for SNF coverage based on the
provided documentation. The enrollee was determined to have documented skilled nursing needs, as he was
receiving IV antibiotics four times per day. The Plan requested a re-opening and submitted new and material
evidence. The Plan states that you were receiving IV antibiotics are the time of the appeal review. The Plan
also notes you completed the IV antibiotics on April 16, 2021 and you were discharged without a skilled need
on April 21, 2021. The medical records show you were admitted to the hospital on March 30, 2021 with
bacteremia due to Enterococcus. You underwent lithotripsy and placement of a right ureteral stent. You were
treated with IV ampicillin. You completed the course of ampicillin on April 16, 2021 and was to continue oral
amoxicillin for prophylactic coverage until evaluated by urology as an outpatient. It is noted that your spouse
made the request for SNF services nearly a week before your planned discharge. The additional documentation
submitted supports that you did not have skilled nursing or therapy needs at the time of his discharge from the
hospital. Medicare coverage criteria were not 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network kidney transplant for the enrollee.

You asked the Plan to pre-approve out of network transplant. You say that the enrollee's preference is to be
treated out of network. The Plan denied your request. The Plan says this treatment can be provided in network.
The Qualified Independent Contractor (QIC) overturned the Plans denial for approval of out of network care. The Plan requested a reopen and states that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a kidney transplant
evaluation with an out-of-network provider. The QIC Physician Reviewer determined that the enrollee needed an evaluation as soon as possible to get on the transplant list. The reviewer found that dual or multiple listing for a kidney transplant is a service that is encouraged by all transplant centers to reduce the amount of time on dialysis. The reviewer said that this was a medically appropriate listing, given that the enrollee has a caregiver in the area.

The Plan requested a reopen and stated the enrollee was already listed on an in-network transplant list in
the State where she has social support. The Plan notes that this listing was not emergent or urgent, as the records
submitted were from 2020.

Our Medical Director has concluded that the Plan is correct in this case. The documentation supports that
transplant services are available in-network. The documentation does not support that the enrollee had an
emergent or urgently needed condition. The enrollee could have foreseen requiring the services prior to leaving
her service area. It would have been medically reasonable to delay the services until the enrollee returns to her
service area (or disenrolled from the plan, or up to 6 months if date unknown - whichever is earliest). Medicare
coverage criteria for out of network care are not 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 out of network transplant have not been met. 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 out of network transplant. Therefore, we decided that the Plan does not have to preapprove
out of network kidney transplant for the enrollee.