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

We decided that the Plan does not have to pre-approve services rendered as part of a clinical trial (S9990).
You asked the Plan to pre-approve the services rendered as part of a clinical trial. You say that the services are medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment for the services at issue.
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 the services rendered as part of a clinical trial 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 services rendered as part of a clinical trial (S9990).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services.

You asked the Plan to pay for these vision services. The Plan denied your request. The Plan says the eyewear benefit is not covered if the services are not ordered through the Plan's designated vendor.

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 ordered through the designated vendor. You did not use a designated vendor. 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 deluxe frames (V2020) spherocylinder, single vision (V2103) anti-reflective coating (V2750) and polycarbonate lens (V2784).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).
You asked the Plan to pre-approve the dental item. You say that your previous upper partial denture broke in half. You also say that you need a new one. The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan also says that the frequency limit has been reached.
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 frequency limit of dentures once every 60 months has been reached. The record shows that the Plan paid for an upper partial denture that you received on August 18, 2016. Additionally, the record also shows that you will be eligible for another upper partial denture on August 18, 2021. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the enrollee has already received 3 injections of Prolia. The Plan denied your request. The Plan says that the enrollee has not tried and failed oral Bisphosphonates.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is medically necessary and reasonable for the enrollee. Our physician reviewer found the enrollee has received previous Prolia therapy. Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or enrollee compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Our reviewer found that step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. Our physician reviewer also found that the requested Prolia is medically necessary and 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia (J0897).

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: Unfavorable

We decided that the Plan does not have to pre-approve insertion of stabilizing or separating device into lower spine at single level (22869).
You asked the Plan to pre-approve the stabilizing or separating device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says there is not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stabilizing or separating device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of stabilizing or separating device into lower spine at single level (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Guardian sensors and a transmitter for a non-therapeutic continuous glucose monitor system.
You asked the Plan to pre-approve the Guardian sensors and transmitter. You say that you would like reconsideration because the member attempts to keep their glucose levels in normal range and the predictive alerts of this system would be beneficial. The Plan denied your request. The Plan says this is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitoring (CGM) devices covered by Medicare under the DME benefit are defined in CMS Ruling 1682R as therapeutic CGMs. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardian sensors and transmitter have not been met. Non-therapeutic CGMs are not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pre-approve Guardian sensors and a transmitter for a non-therapeutic continuous glucose monitor system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve the facet joint injections. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the proposed treatment for a medial branch block would not adequately treat this member's pain.

The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet the criteria listed above. 

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 facet joint injections. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the member has multiple other pain generators. 

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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy to be provided by an out-of-network provider.
You asked the Plan to pre-approve psychotherapy. You say that the Plan cut funding and only offered monthly visits. You say that Plan therapists are low quality, and you are requesting to return to your outside provider. The Plan denied your request. The Plan says services are available in-network.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a surgical repair of a hip fracture after a fall. Your medical problems are stable. 

You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 

Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
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. No clinical documentation was provided to show that the enrollee meets coverage criteria. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the RevoFit socket.

You asked the Plan to pre-approve the RevoFit socket. You say that you would like reconsideration because the member needs the socket to be mechanically adjusted to match the residual limb volume. The Plan denied your request. The Plan says the RevoFit does not have FDA approval.

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 RevoFit socket. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of long-term effectiveness and safety in the literature for the use of the RevoFit. 

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 RevoFit socket have not been met. Therefore, we decided that the Plan does not have to pre-approve the RevoFit socket.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 irrigation sleeves.
You asked the Plan to pre-approve the 5 irrigation sleeves. You say that you would like reconsideration because your physician recommended that you maintain your ostomy by irrigating every other day. The Plan denied your request. The Plan says the additional 5 irrigation sleeves are not medically necessary.
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 5 irrigation sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you reported that you irrigated your ostomy every other day. According to this statement, you should not require more than 15 sleeves per month. 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 5 irrigation sleeves have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 irrigation sleeves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core build up (D2950) for tooth # 9.
You asked the Plan to pre-approve the dental services. You say that a crown was previously placed on tooth # 9 on May 26, 2015. You say that the crown and tooth display darkening on the gingival and mesial. You also say that worsened caries are possible. The Plan denied your request. The Plan says crowns are not covered for cosmetic reasons or for closing gaps.
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, crowns are not covered for cosmetic reasons or for closing gaps. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core build up (D2950) for tooth # 9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-invasive vagus nerve stimulator (VNS) (E1399).

You asked the Plan to pre-approve the nerve stimulator. You say that the enrollee requires the device for
migraine headaches. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria,
there is not enough established evidence for using VNS for the treatment of migraine headaches.

The Plan must follow Medicare rules. Medicare rules say that VNS is only used in certain circumstances,
namely for treatment of refractory epilepsy and for resistant depression.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve
non-invasive vagus nerve stimulator (VNS) (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee and billed under code G0481.

You asked the Plan to pay for this testing. 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 information. The Plan stated that this claim denied because this service does not meet the criteria for the category under which it was billed. The Plan states that this claim was coded incorrectly. The Plan states the records do not contain documentation of definitive laboratory results for 8-14 drug classes, including metabolites to support the coding criteria for G0481. The records contain documentation of definitive laboratory results for six drug classes. The Plan provided the specific records that show only six drug classes were testing.

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. In this case, this claim cannot be paid as billed because only six drug glasses were shown to be tested. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee and billed under code G0481.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deep sedation services provided on August 11, 2020 and billed under codes D9222 and D9223.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says these are adjunct codes that are only covered when specific services are performed. Maximus partially overturned the Plans denial and stated these services show as a listed service in the Plan's Contract. The Plan requested a reopen and stated that Maximus did not interpret the contract correctly. The Plan states that coverage for deep sedation/anesthesia (D9222 and D9223) is not covered under the member's Plan for the dental procedure D7210 (Extraction, erupted tooth ) which are the dental procedures you received.
The Plan is correct in this case. 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, deep sedation is only covered as an add on or adjunct service with codes D7230, D7240 and D7241. You did not receive any of these services. Deep sedation is not covered as an adjunct code with D7210 or extractions, which is the service you received. Therefore, we decided that the Plan does not have to pay for deep sedation services provided on August 11, 2020 and billed under codes D9222 and D9223.