Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).
You asked the Plan to pre-approve the PMD. You say that you cannot get around without the power wheelchair. You say that you have reduced mobility and chronic obstructive pulmonary disease. The Plan denied your request. The Plan says the seating and mobility assessment completed on July 7, 2021, indicated that the enrollee is able to walk unassisted in his home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 PMD. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee had a personal mobility deficit due to dyspnea, but it is not clear that it impairs participation in mobility related activities of daily living in the home or that the enrollee's mobility deficit is unable to be helped by the use of a walker or manual wheelchair or cane. The July 7, 2021, mobility deficit states the enrollee walks without an assistive device. While the enrollee may be able to safely operate a PMD in the home, the documentation does not indicate that it is medically necessary. As a power operated vehicle is not medically necessary, repairs to the patient's current power mobility device is not 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 the PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for diagnostic imaging provided by a participating provider on November 17, 2020, to March 3, 2021.
You asked the Plan to waive the coinsurance for an injection and copayment for diagnostic imaging. You say that you think this is ridiculous. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct charges have been applied.
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 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment for outpatient diagnostic tests/diagnostic tests.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $40 copayment for diagnostic imaging.
Date of Service
CPT Code
Allowed Amount
Coinsurance
Copayment
Total
11/17/2020
---
---
---
---
$0
12/21/2020
J0178
$1,856.48
20%
---
$371.30
01/20/2021
J0178
$1,856.48
20%
---
$371.30
01/20/2021
99250
---
---
$40
$40
03/03/2021
99250
---
---
$40
$40
Total Amount Being Asked to Pay: $0 + $371.30 + $371.30 + $40 + $40 = $822.60
An injection falls within the Medicare Part B prescription drugs benefit category and diagnostic imaging falls within the outpatient diagnostic tests/diagnostic tests 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 coinsurance for an injection and copayment for diagnostic imaging provided by a participating provider on November 17, 2020, to March 3, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate care, and a transfer would not offer a clinical advantage.

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 they are 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 12, 2020.
You asked the Plan to pay for the orthosis. You say that the Plan failed to timely pay the bill. The Plan denied your request. The Plan says enrollees are not initiating a request to be contacted.
The Plan follows 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 the orthosis at issue in this appeal 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. The record does not 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 have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat therapeutic facet joint injections.

You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). You say that the enrollee is getting relief from the injections. The Plan denied your request. The Plan says the guidelines do not allow for this method of blocking the facet joints unless there has been some reason such as abnormal anatomy from surgery or some other established reason.

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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD specifically does not allow for repeat intra-articular facet injections rather than RFA unless there is a specific anatomic issue. 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 injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494) have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat therapeutic facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee.

You asked the Plan to pre-approve proton beam radiation therapy. You say that this treatment is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated 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 Proton Beam
Radiation Therapy (PBRT). The QIC Physician Reviewer determined that the criteria for coverage were
met. The Plan requested a reopen and stated that the use of Proton Beam Therapy for the treatment of prostate
cancer is "not supported by the LCD and NCCN guidelines due to the enrollee is not enrolled in a clinical trial
for evidence development and the provider documents proton beam offers no benefit over photon
radiotherapy." The Plan notes that the enrollee is not enrolled in a procedure-specific or clinical trial for
evidence development, but rather is in an observational study. The medical records show the enrollee is a 72-
year-old man with a history of favorable low-risk prostate adenocarcinoma diagnosed in early 2019, with
progression to intermediate-risk disease. The radiation oncologist discussed multiple treatment options with the
enrollee on February 22, 2021.

Our Medical Director has concluded that the Plan is correct in this case. The medical records do not contain
documentation that the surrounding normal tissue cannot be adequately achieved with photon-based
radiotherapy and that photon beam therapy is of added clinical benefit to the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules.

Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have
not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy
for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested 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 considered medically reasonable and necessary in this case. Our physician reviewer found that 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 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 Plan.
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 the LTACH services.
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 the SNF services. You say that the medical records provided support the need for a continued SNF stay. The Plan denied your request. The Plan says SNF care is no longer medically necessary. The Plan says that the enrollee does not required daily skilled therapy services.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision level with functional mobility with gait to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (78803) provided on January 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column two
code and is not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 78803 is part
of an edit pair with procedure code 79445. Procedure code 79445 is a column one code, and procedure code
78803 is a column two code. Procedure code 79445 has been billed for this date of service, which means that
procedure code 78803 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for
the services (78803) provided on January 19, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda, Carboplatin, and Alimta.
You asked the Plan to pre-approve Keytruda, Carboplatin, and Alimta. You say that this request is medically necessary. The Plan denied your request. The Plan says that this requested drug regiment is not recommended.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda, Carboplatin, and Alimta. Our reviewer says that the requested drug regiment is medically necessary and reasonable. Our physician reviewer found in this case, the enrollee has been diagnosed with non-small cell lung cancer in 2007. In this case, Keytruda, Carboplatin, and Alimta are FDA-approved for the enrollee's condition. The requested drug regiment is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda, Carboplatin, and Alimta have been met. Therefore, we decided that the Plan has to pre-approve Keytruda, Carboplatin, and Alimta.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on May 26, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is a more appropriate code that should be used for the service provided.
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 97163 is a high complexity physical therapy evaluation. A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
We find that CPT code 97163 is not supported in the medical record. The records show that the enrollee was seen for muscle weakness after a fall with hip fracture. The enrollee required contact guard assist for functional transfers. The records do not show that the enrollee presented with unstable or unpredictable characteristics. 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 physical therapy services provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye exam with refraction (92014, 92015) and a pair of eyeglasses (V2020).
You asked the Plan to pre-approve an eye exam with refraction and a pair of eyeglasses. You say that you need new eyeglasses with a different prescription. You need a low-vision eye doctor and the doctor you saw previously was not up to par. The Plan denied your request. The Plan says rules for coverage have not been met because you have exhausted the benefit for the 2021 calendar year.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 routine eye exam with refraction and dilation per calendar year and 1 pair of eyeglasses per year with frame, lenses, and fitting. We looked at the file and the Plan's rules. The record shows that you used your vision benefits for the year in January 2021. Based on this information, we decided that the Plan's rules for coverage of an eye exam with refraction and a pair of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve an eye exam with refraction (92014, 92015) and a pair of eyeglasses (V2020).
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Your complaint about exhausting your vision benefit without receiving a satisfactory pair of eyeglasses is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.