Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopic partial gastrectomy with Roux-en-y reconstruction for the enrollee.
You asked the Plan to pre-approve laparoscopic partial gastrectomy with Roux-en-y reconstruction. You say that this procedure is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans decision. 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 laparoscopic partial gastrectomy with Roux-en-y reconstruction. The Maximus Physician Reviewer determined that the requested surgery was medically reasonable and necessary in this case. Our physician reviewer found the enrollee met all primary criteria for bariatric surgery. Conversion to laparoscopic Roux-en-y gastric bypass is a standard operative treatment for post sleeve gastrectomy GERD and bile reflux. The Plan requested a reopen stating the correct criteria were not applied. The enrollee is a 67-year-old woman with a history of morbid obesity. The enrollee underwent laparoscopic sleeve gastrectomy in 2015, and initially had weight loss. Since then, the enrollee has regained much weight, and has bile reflux. Our Medical Director has concluded that the Plan is correct in this case. The appeal was originally reviewed on November 11, 2020 and the determination was unfavorable at that time. When the case was reviewed on February 4, 2020 there were no significant clinical changes that necessitated a change in the determination.
The Medicare LCD L33411 states that repeat bariatric surgery is generally not reasonable and necessary. The clinical circumstances in this case do not demonstrate reasonability and necessity, such as replacing a defective device, or correcting a complication in a patient who had met medical necessity for the original procedure and has achieved acceptable weight loss. Medicare coverage criteria 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 laparoscopic partial gastrectomy with Roux-en-y reconstruction have not been met. Therefore, we decided that the Plan does not have to pre-approve laparoscopic partial gastrectomy with Roux-en-y reconstruction for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services. You asked the Plan to pre-approve the CT scan. You say that the office notes and letter from the ordering physician support the necessity and urgency of the requested CT scan. The Plan denied your request. The Plan says the requested CT scan is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the medical records provided do not support the need for a CT scan. There are no specific urological indications such as hematuria, complicated UTI, or renal colic noted in the medical records. The most likely cause of cystitis in older males is BPH with bladder outlet obstruction. The records do not indicate that this enrollee has been evaluated for BPH with bladder outlet obstruction. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 27, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on October 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on October 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on February 10, 2021.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because CPT code 99214 was temporarily added for telehealth services. The Plan denied your request. The Plan says the documentation does not support that this provider rendered services on the billed date of service and the place of service code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code 99214 is not supported in the record. Specifically, the documentation submitted does not include any medical records to verify the services billed and if Medicare coverage criteria have been met. Additionally, it is not appropriate to bill place of service code 12 for the member's home with CPT code 99214. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on February 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound (76770) provided January 20, 2021.You asked the Plan to pay forthe ultrasound. You say that the service should be covered.The Plan denied your request. The Plan says the deductible was not met at the time the services were rendered.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract withthe Plan says that there is a $750 deductible for basic radiology services. The item or service you asked the Plan to pay for falls within the benefit category basic radiology services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for basic radiology services. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on January 20, 2021.Therefore, we decided that the Plan does not have to pay foran ultrasound (76770) provided January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound (73562, 93971) provided December 30, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that the copayment should be lowered.The Plan denied your request. The Plan says the correct cost-sharing was applied.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for diagnostic tests. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the 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 copayment foran ultrasound (73562, 93971) provided December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cardiac vest (K0606) provided October 4, 2020 to December 4, 2020.
You asked the Plan to waive the coinsurance for the cardiac vest. You say that you no longer need the vest and the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 15% coinsurance for Durable Medical Equipment.
You have been asked to pay a 15% coinsurance for the cardiac vest. The cardiac vest falls within the Durable Medical Equipment 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 a cardiac vest (K0606) provided October 4, 2020 to December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fitted power wheelchair with features.
You asked the Plan to pre-approve a custom fitted power wheelchair with features. You say that you would like
the Plan to reconsider their denial. The Plan denied your request. The Plan says durable medical equipment is
not covered when the enrollee resides in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that a custom fitted power wheelchair with features is being requested for use in a SNF or
hospital. Therefore, we decided that the Plan does not have to pre-approve a custom fitted power wheelchair
with features.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), the filling (D2331 x 2), the comprehensive oral evaluation (D0150), prophylaxis (D1110), the fluoride varnish application (D1206), and the complete series x-ray (D0210) provided from August 27, 2020, to October 21, 2020.

You asked the Plan to pay the in network rate for the dental services. You say that you were advised by a plan representative that this provider's office was in network. You say that the provider's office advised they were in network on or around August 27, 2020. You say that the provider's office advised they were out of network on or around October 15, 2020. You also say that the services should be paid at the in network rate due to misinformation. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for any amount greater than what the plan pays. The Plan also says that the provider confirmed that the incorrect plan information was provided to them when determining network status.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, out of network providers may bill you for any amount greater than what the plan pays. Member liability is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), the filling (D2331 x 2), the comprehensive oral evaluation (D0150), prophylaxis (D1110), the fluoride varnish application (D1206), and the complete series x-ray (D0210) provided from August 27, 2020, to October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no plan supplemental benefit for this.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. This is being requested for Bell's palsy. There is a limited benefit for low back pain for acupuncture. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services.
You asked the Plan to pre-approve the continuation of SNF services. You say that that the therapists indicated that the enrollee is at a high risk for falls and needs 24-hour supervision. You say he also needs to learn how to move without twisting or bending to avoid any damage to the back while it heals. The Plan denied your request. The Plan says ongoing inpatient SNF services do not appear to be medically reasonable and necessary after May 6, 2021.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs and he was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was modified independent to supervision level with functional mobility including gait to 400 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 require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal cord stimulator (SCS) trial.You asked the Plan to pre-approvethese services. You say that the enrollee is in severe pain.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are met.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 he services are not medically necessary. Our physician reviewer found the enrollee has bilateral foot pain. Magnetic resonance imaging (MRI) shows an extruded disc at L4-L5 and a disc bulge at T6. There is no documentation of a surgical consultation, epidural steroid injections, or a psychological evaluation. The criteria for coverage are not met and the services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator (SCS) trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 3, 2021.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on May 19, 2021 after hospitalization for a fall and femur fracture. She received oral medications and had stable vital signs. She received physical and occupational therapy in the SNF and is dependent for functional mobility and is non-ambulatory. She needs varied assist with activities of daily living. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of inpatient skilled nursing facility care.
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 SNF care. Our reviewer says that
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee
does not have documented skilled nursing or skilled therapy needs. The enrollee appears to be functioning
at/near his baseline. The enrollee's care needs at this point are custodial and, as a practical matter, can be
provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve inpatient skilled nursing facility (SNF) care.