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

We decided that the Plan does not have to pre-approve increased dosage of allergy injections (subcutaneous immunotherapy).
You asked the Plan to pre-approve the increased allergy injection dosage. You say that the enrollee had improved symptoms with prior treatments for which the dose had been reduced over time. Due to new exposure to cat dander, this allergen was added to the serum. The new serum was not proving as effective so it is felt that slightly increasing the total dose is needed to return to the prior improvement of symptoms. The Plan denied your request. The Plan says these treatments are not medically necessary. They have never been covered by the Plan and no coverage should be allowed for them.
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 increased allergy injection dosage. Our reviewer says that there is not sufficient evidence to support the medical necessity for the patient to receive these injections. Our physician reviewer found there was no documentation of improvement with antigen therapy. There was no documentation of improvement in clinical scores. The review has determined that the documentation does not support that the antigen treatments being requested in this case are medically reasonable and necessary for this 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 the increased allergy injection dosage have not been met. Therefore, we decided that the Plan does not have to pre-approve increased dosage of allergy injections (subcutaneous immunotherapy).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two alveoloplasty procedures (D7310) to be performed in conjunction with extractions.
You asked the Plan to pre-approve the alveoloplasty procedures. You say that these services are necessary so you can be properly fitted for dentures. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two alveoloplasty procedures (D7310) to be performed in conjunction with extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cochlear implant mapping to be provided by the out-of-network
provider.

You asked the Plan to pre-approve the Cochlear implant mapping. The Plan denied your request. The Plan says
there are in-network providers in the enrollee's area where this service can be 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the Cochlear implant mapping. We found no exception that would require the Plan
to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve Cochlear implant
mapping to be provided by the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron.

You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says Medicare covers routine costs of a clinical trial.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve Palonosetron as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Palonosetron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.
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
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implants (D6010) for tooth 29 and 30.

You asked the Plan to pay for the two endosteal implants. You say that the service should be covered. The Plan denied your request. The Plan says you have met your benefit limit for this service.

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. The Plan covers the endosteal implants once every five years.

We looked at the file, and Medicare rules. The Plan has already agreed to cover one endosteal implant. Therefore, we decided that the Plan does not have to pay for the endosteal implants (D6010) for tooth 29 and 30.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy and 4 additional occupational therapy home health visits.
You asked the Plan to pre-approve 5 additional physical therapy and 4 additional occupational therapy home health visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 5 additional physical therapy and 4 additional occupational therapy home health visits. Our reviewer says that the documentation does not support
that the requested services are medically reasonable or necessary. Our physician reviewer found that the documentation does not reveal that the enrollee's functional need demonstrates that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been authorized additional therapy to review home exercise program. The enrollee does not require the ongoing needs of an occupational therapist for activities of daily living training. The requested services are not part of a maintenance program and do not require the knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the enrollee does not meet criteria for the requested 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 5 additional physical therapy and 4 additional occupational therapy home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy and 4 additional occupational therapy home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered.

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 provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pilocarpine.

You asked the Plan to pre-approve Pilocarpine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Pilocarpine.

Benefits for Pilocarpine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a knee orthosis (L1851) for the enrollee.
You asked the Plan to pre-approve a knee orthosis (L1851). You say that this orthosis is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of orthosis. 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 a knee orthosis (L1851). Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found the medical records show the enrollee has right knee osteoarthritis. The pain is worsened by activity and has not been effectively treated with anti-inflammatory agents. The examination indicates that the Lachman test is positive. At issue is whether knee orthosis (L1851) for this enrollee is a covered service under Medicare rules. Under Medicare rules, the knee orthosis is a covered service if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or knee instability is demonstrated by objective description of joint laxity. In this case, there is a well-documented physical examination as well as the demonstration of knee instability. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis (L1851) have been met. Therefore, we decided that the Plan has to pre-approve a knee orthosis (L1851) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary implant /abutment supported removable denture for edentulous arch (D6110) and a mandibular implant /abutment supported fixed denture for edentulous arch (D6115).
You asked the Plan to pre-approve the maxillary implant /abutment supported dentures. The Plan denied your request. The Plan says these services are not covered benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary implant /abutment supported removable denture for edentulous arch (D6110) and a mandibular implant /abutment supported fixed denture for edentulous arch (D6115).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker (E1399).
You asked the Plan to pre-approve the upright walker. You say that the upright walker is medically necessary. The Plan denied your request. The Plan says a standard four-wheeled walker has already been provided and meets the enrollee's needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a four-wheeled walker and a Power Scooter. These mobility aids serve the same purpose as the upright walker. Therefore, we decided that the Plan does not have to pre-approve an upright walker (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee does not check blood glucose levels four or more times per day. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The documentation shows that the enrollee is able to walk up to 240 feet independently. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. As a practical matter, the enrollee does not require the necessary services on 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the Sinus
(70486).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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
CT scan is not medically necessary. Our physician reviewer found the symptoms were suggestive of allergies
or other irritation. There was no documented allergy testing or other workup required prior to considering CT
imaging. There was no report or signs or symptoms suggestive of sinusitis or other condition which might
warrant imaging.
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 a Computed Tomography (CT) scan of the Sinus (70486).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223) for a dental procedure.

You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you have panic attacks, and it is necessary for you to be sedated during your dental procedure. The Plan denied your request. The Plan says this is not a service that is covered by Medicare or by the Plan's supplemental dental benefit.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222, D9223) for a dental procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that the total electric hospital bed is medically necessary. The Plan denied your request. The Plan says the requested type of hospital bed 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 Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that the benefits are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that these benefits are not covered under Medicare. In this case, the plan's rules apply. We looked at the file and the plan's rules. The enrollee does not suffer from one of the listed chronic conditions for which these benefits can be approved. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 30, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says that the provider needed to bill the anatomic specific modifiers LT (Left side), RT (Right side), or 50 (Bilateral procedure) to designate the area or part of the body on which the procedure is performed. The Plan provided the claim showing the provider billed this service without the appropriate modifier. Modifiers provide a means by which a service can be altered without changing the procedure code. They add more information, such as the anatomical site, to the code. In addition, they help to eliminate the appearance of duplicate billing and unbundling. Modifiers are used to increase accuracy in reimbursement, coding consistency, editing, and to capture payment data.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary the appropriate modifiers. In this case, while it is understood the knee was imaging, more specific coding and modifier reporting is required to specifically describe and bill the services rendered. Medicare rules for coverage of this claim are not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on May 30, 2020.