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

We decided that the Plan does not have to pre-approve chiropractic treatment.
You asked the Plan to pre-approve chiropractic treatment. 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 Medicare does not cover chiropractic maintenance care. 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 chiropractic treatment. Our reviewer says that the documentation does not support that the requested chiropractic services are medically reasonable or necessary. Our physician reviewer found there are no submitted imaging studies to reveal evidence of a subluxation. The submitted office visit notes reveal mainly postural disturbances such as gait is forward flexed, rounded forward head, left hip in abduction and myospasms of the posterior cervical muscles secondary to an exaggerated kyphosis and forward head, along with range of motion notations, do not reveal evidence of subluxation per Medicare guidelines. The documentation supports that the requested services are for maintenance therapy. There is no evidence from the submitted documentation that improvement has occurred or will occur with additional chiropractic visits. The treatments are maintenance therapy and are not supported or allowed per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a reclining chair.
You asked the Plan to pre-approve the reclining chair. You say that you do not know why this would not be covered. You state you have cancer and have had several surgeries leaving you bedbound. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Although Medicare may cover a seat lift mechanism for use with an armchair, this must be prescribed by your physician. There is no evidence that your physician has prescribed a seat lift mechanism for you. Therefore, we decided that the Plan does not have to pre-approve a reclining chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an additional anterior segment aqueous drainage device.
You asked the Plan to pre-approve eye surgery. You say that this code is only used in conjunction with the primary procedure, and it applies when an additional iStent is implanted during the same session. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the iStent is covered with the primary billing code 0191T and this second requested code is redundant.
The Plan must follow Medicare rules. Medicare rules say that procedure code 0376T is not considered medically necessary and is not covered by Medicare. We looked at the file and Medicare rules. The Plan approved the primary procedure code for the iStent placement; however, this additional code would not be covered by Medicare. Based on this information, we decided that Medicare rules for coverage of eye surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an additional anterior segment aqueous drainage device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for epidural injections, interlaminar injections, paravertebral muscle injections, anesthesia, and fluoroscopic guidance provided on September 6, 2019.
You asked the Plan to pay for surgical services, anesthesia, and fluoroscopic guidance. You say that you do not agree with the amount the Plan has paid for these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were 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 pay for surgical services, anesthesia, and fluoroscopic guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you did not meet the required coverage criteria for the trigger point injections performed. Regarding the umbilical cord tissue products, these have not been determined by the Food & Drug Administration (FDA) to be an effective treatment. The other services and guidance are not needed given that the primary procedures are not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical services, anesthesia, and fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for epidural injections, interlaminar injections, paravertebral muscle injections, anesthesia, and fluoroscopic guidance provided on September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the treatment goals are to keep pain at a tolerable level with the least amount of medication. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the notes do not show a physical examination and 6-week trial of physical therapy.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered when the enrollee meets all of the clinical 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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the presence of radicular pain indicates that there is probably another pain generator, which does not meet the Medicare criteria, and therefore the requested procedure is deemed not medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you do not know why this was denied because you 
have to prick your fingers daily and you feel this would make testing your blood sugar easier. The Plan denied 
your request. The Plan says you do not meet the criteria for the CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered for enrollees who test their 
blood sugar four or more times per day and require three or more insulin injections that need to be adjusted 
frequently based on blood sugar readings.  
 
The records provided show that you test your blood sugar only twice per day and need only a single insulin 
injection per day. As such, the criteria for coverage of the CGM are not met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensive outpatient behavioral health treatment 
beginning May 21, 2020. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found based on the submitted records, the 
enrollee does not have any suicidal or homicidal ideation, auditory or visual hallucinations, or psychosis. He 
does not have any medical issues that require the intensive outpatient level of care. There is no report that he 
requires assistance with activities of daily living. He is participating in a treatment plan and attending 12-step 
groups. He is not a danger to himself or others. The intensive outpatient level of care is 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 for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensive outpatient behavioral health treatment beginning May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for an external infusion pump. 
 
You asked the Plan to pre-approve the requested supplies. The Plan denied your request. The Plan says the 
requested supplies are not covered under the plan. 
 
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 A4230 is Infusion set for external insulin pump, non-
needle cannula type. The CPT Code Manual definition of code A4232 is Syringe with needle for external 
insulin pump, sterile, 3 cc. We find that CPT codes A4230 and A4232 are not valid for Medicare purposes. 
Medicare uses other codes for reporting of, and payment for, these services. 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 pre-approve supplies for an external infusion pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you were on a cruise when you fell and 
fractured your hip. You say that you had to have surgery and now you need the requested orthotics to help 
straighten out your walking pattern. You stated that with the orthotics you will not have to put as much 
pressure on one leg to compensate for the other. You say that you cannot fully walk around because of the pain 
of having to limp and put pressure on your leg. You asked the Plan to reconsider providing coverage. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve virtual colonoscopy for the enrollee.
You asked the Plan to pre-approve the colonoscopy. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 colonoscopy. Our reviewer says that the requested colonoscopy is not medically reasonable or necessary. Our physician reviewer found the enrollee has a greater than average risk of existing colon pathology, and that colon re-surveillance at this time may identify colonic adenomas that require removal. As such, colon re-examination in 2020 cannot be considered "screening" in the enrollee's case. Protocols are specialty-society required and in place at most endoscopy centers to significantly limit COVID-19 exposure risk during colonoscopy performance. On the other hand, Medical Center site-of-care exposure as planned for the enrollee's proposed CT colonography engenders her heightened COVID-19 risk. Further, the enrollee meets no standard of care medical necessity indications for CT colonography in lieu of optical colonoscopy which is indicated at this clinical juncture. 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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve virtual colonoscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for pain injections. 
 
You asked the Plan to pre-approve the anesthesia. The Plan denied your request. The Plan says this is 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 anesthesia. Our reviewer says that 
the requested anesthesia is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee does not have OSA, is not morbidly obese, is not spastic, and does not have 
any unstable medical condition. There is  no indication for anesthesia monitoring, and the ASA committee on 
pain specifically recommends against providing IV analgesia as it may interfere with the results. 
 
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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anesthesia for pain injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transvenous phrenic nerve stimulator (TPNS). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TPNS 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 
the services are not medically necessary. Our physician reviewer found the enrollee has central sleep apnea 
(CSA) and is intolerant to positive airway pressure (PAP) therapy. He is on daily narcotics for control of 
chronic pain, and narcotics can cause central sleep apnea. The most appropriate treatment for narcotic-related 
CSA is finding alternatives for pain control in order to reduce or eliminate the narcotics. The records do not 
show that this has been tried and failed. TPNS has not been studied in patients with narcotic-related CSA. The 
criteria for coverage are not met and the TPNS is 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 for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transvenous phrenic nerve stimulator (TPNS).  
 
Local Coverage Determination (LCD) L35094 referenced by the Plan is retired and was not used in the 
MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a gastroenterology evaluation. 
 
You asked the Plan to pre-approve a gastroenterology evaluation. The Plan denied your request. The Plan says 
that this is not medically necessary. 
 
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 a gastroenterology evaluation. Our 
reviewer says that the requested a gastroenterology evaluation is considered medically reasonable and 
necessary in this case. Our physician reviewer found that assuming the accuracy of enrollee's past medical 
history, the constellation of current complaints and of weight loss in the context of follicular lymphoma and 
history of colonic adenomata constitutes medical necessity for the requested gastroenterology evaluation. 
 
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 gastroenterology evaluation have been met. Therefore, we decided that the 
Plan has to pre-approve a gastroenterology evaluation.  
 
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 genicular nerve radiofrequency ablation 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 this is still being studied in clinical trials for efficacy in the treatment of knee pain due to 
osteoarthritis or in the setting of replacing or significantly deferring total knee arthroplasty (TKA). 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure. The studies to date have focused on osteoarthritis 
related pain, which the enrollee does not have. Therefore, the request is considered not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and lung cancer. A CT scan from October of 2019 revealed a left upper lobe chest lesion, increasing mediastinal nodes, and resolving left lower lobe pneumonia. The requested CT scan of the chest is reasonable and medically necessary to evaluate the left upper lobe lesion site. 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 a computed tomography (CT) scan of the chest.
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, abdomen; without contrast material (71450). 
 
You asked the Plan to pre-approve the CT scan. You say that your provider is asking for CT scan of abdomen 
to examine your liver because you had an abnormal liver test. The Plan denied your request. The Plan says the 
provider did not give the Plan records showing test results after your medicine's were changed. 
 
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 physician reviewer 
found it does not appear that sufficient workup has been done to warrant a CT scan. Certainly not anything is 
differential that could not be diagnosed with ultrasound. Treatment plan was not documented to support CT 
scan of abdomen for this diagnosis. 
 
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 CT scan, abdomen; without contrast material (71450).