Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the home fitness equipment you received on September 24, 2020, and October 7, 2020.
You asked the Plan to pay for the equipment. The Plan denied your request. The Plan says the items were purchased prior to the benefit exception.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The items at issue in this appeal are home fitness equipment. The Plan does not pay for home fitness equipment. However, during the COVID-19 pandemic, the Plan made a benefit exception to cover home fitness equipment from October 1, 2020, to December 31, 2020. The equipment you received on September 24, 2020, was purchased prior to the benefit exception, and is not covered. The Plan has agreed to reimburse you for the equipment you received on October 7, 2020, minus the shipping and delivery fees. Therefore, we decided that the Plan does not have to pay for the home fitness equipment you received on September 24, 2020, and October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee currently has a manual wheelchair to use in the 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal a detailed home assessment indicating that the enrollee can safely maneuver the scooter in the home. The documentation does not reveal that a scooter will significantly improve MRADLs in the home. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 25, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. We find that the claim was not billed with the place of service where the
enrollee's sample was taken. 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 lab services provided on March 25,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary, due to the diagnosis of type 2 diabetes mellitus. The Plan denied your request. The Plan says the criteria have not been met.
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 monitor. Our reviewer says that the requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have type II diabetes, which is noted to be both insulin dependent and without long-term use of insulin. The enrollee's medication list notes fixed doses of thrice daily short-acting insulin and once daily long-acting insulin. A blood glucose log indicates that the enrollee tests her blood glucose thrice daily. There is no evidence that the enrollee uses the results of this testing to self-adjust insulin doses multiple times per day. As such, the use of a CGM is not shown to be 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary for treatment of right lower extremity lymphedema. The Plan denied your request. The Plan says the requirements were not met.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee has objective physical exam findings of lymphedema of the chest, trunk, or abdomen. There is no evidence of unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel provided on June 2, 2020.
You asked the Plan to pay for the testing services. You say that the test can prevent dangerous medication interactions. The Plan denied your request. The Plan says one code must be submitted for a panel.
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 the pharmacogenomics panel was not billed with a code indicating one single procedure was performed. 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 pharmacogenomics panel provided on June 2, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve a magnetic resonance spectroscopy (MRS) (76390).
You asked the Plan to pre-approve a magnetic resonance spectroscopy (76390). You say that this imaging 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 Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for MRS spectroscopy (MRS). The Maximus Physician Reviewer determined this imaging may be appropriate. The Plan requested a reopen and stated NCD 220.2.1 states that MRS is investigational and non-covered for all indications. Our Medical Director has concluded that the Plan is correct in this case. The NCD for Magnetic Resonance Spectroscopy, 220.2.1, specifically states MRS is not covered 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 MRS have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance spectroscopy (MRS) (76390).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit.

You asked the Plan to waive the copayment for the urgent care visit. You say that you were only there for a
Covid-19 test. You say the 30-second video conference with the doctor should not be considered a specialist
visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40
copayment for an urgent care center.

You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The medical record shows you had vitals taken in addition to the
Covid-19 test. 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 the urgent care visit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health speech therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says treatment goals were met earlier than anticipated.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services are not medically reasonable or necessary. Our physician reviewer found the requested additional speech therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has had instructions on safe swallowing, is at baseline cognitive communication, and can tolerate an advanced diet. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health speech therapy services for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Laparoscopic Hysterectomy (58548) and exploration of abdomen (58960) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that there are no medical records to support that the member met the guidelines for these procedure.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 requested services are considered medically reasonable and necessary in this case. The patient still has a thickened endometrial stripe after the Dilation and Curettage hysteroscopy on ultrasound and, after counseling regarding her options, the patient desires definitive diagnosis and treatment of her postmenopausal bleeding with hysterectomy. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these services. 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 been met. Therefore, we decided that the Plan has to pre-approve Laparoscopic Hysterectomy (58548) and exploration of abdomen (58960) for the enrollee.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Retacrit injection.

You asked the Plan to pay for Retacrit. The Plan denied your request. The Plan says that the enrollee did not have an indicated diagnosis.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

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 Retacrit. Our physician reviewer found that the enrollee has a medical history of anemia who was taking iron replacement medication. An epoetin alfa-epbx (Retacrit) injection was provided. Based on the medical records provided, there is documentation that the enrollee had a condition that is indicated for coverage. The enrollee, on laboratory testing, had a hemoglobin level of 8.6 grams/dL, a glomerular filtration rate of 32 mL/minute, and a ferritin level of 30.3 ng/dL. Anemia of chronic kidney disease with a hemoglobin level less than 10 grams/dL is a medically-accepted indication for Retacrit. There is documentation that the provided Retacrit injection was medically reasonable and necessary to treat the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pay for the Retacrit injection.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor for the enrollee.
You asked the Plan to pre-approve a Freestyle Libre Sensor. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of this item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Sensor for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lymph node biopsy billed for services provided on
August 27, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
services cannot be verified.
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 38510 is biopsy or excision of lymph node(s); open, deep
cervical node(s). We looked at the file and the rules. We find that CPT code 38510 is not supported in the
medical record. Based on this information, we decided that Medicare rules for coverage of the services
provided have not been met. Therefore, we decided that the Plan does not have to pay for the lymph node
biopsy billed for services provided on August 27, 2020.
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 the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a home evaluation.
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found it is not clear that your personal mobility deficit impairs participation in MRADLs in the home. It is not clear why the mobility deficit cannot be helped by a walker or manual wheelchair in the home. The documentation does not reveal a detailed home assessment indicating that you can safely maneuver the wheelchair in your home. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies (A4221 and A4222) provided on February 19, 2020, through February 26, 2020.
You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a valid physician order for the billed supplies.
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 physician order for the supplies provided in this case. 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 the infusion supplies (A4221 and A4222) provided on February 19, 2020, through February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services received on July 15, 2020.
You asked the Plan to pay for the vision services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
received by an out of network provider.
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 these services when they are received by a participating provider.
We looked at the file and the Plan's rules. The Plan covers vision services when received by a participating
provider. Review of the file shows that the services were not received by a participating provider. Based on this
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore,
we decided that the Plan does not have to pay for the vision services received on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four (TOF) monitoring (CPT 95999) provided on August 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four (TOF) monitoring (CPT 95999) provided on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 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 testing is not covered.
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 was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on October 15, 2020.