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

We decided that the Plan has to pre-approve a subcutaneous cardiac rhythm monitor (33285).
You asked the Plan to pre-approve the subcutaneous cardiac rhythm monitor. You say that this service is
medically necessary. The Plan denied your request. The Plan says that it is not reasonable or necessary for the
member to have an implanted device without failing standard external monitoring when these conditions are
present.
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 the subcutaneous cardiac rhythm
monitor. Our reviewer says that the requested items/services are considered medically reasonable and
necessary given the likely improved detection of atrial arrhythmia compared to external monitoring in this
clinical situation. Our physician reviewer found the member may have occult atrial fibrillation as the cause of
cryptogenic stroke and he is not a good candidate for anti-coagulation. Implantable Loop Recorders have been
shown to have a much better yield at detecting sub-clinical atrial fibrillation.
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 subcutaneous cardiac rhythm monitor have been met. Therefore, we decided
that the Plan has to pre-approve a subcutaneous cardiac rhythm monitor (33285).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on August 21, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99291 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99291 (1 Units) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. 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 pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee on August 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) services.
You asked the Plan to pre-approve PT services. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 PT services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found for debility, physical therapy (PT) is generally accepted as specific
and effective therapy. Goals include reducing mobility limitations, restoring function, and educating regarding
a home exercise program (HEP) prior to transition towards a home program. In this case, there is no indication
prior PT has served to provide sustained, significant improvement in pain and/or function and there are no
indication residual deficits could not be addressed via a home exercise program. Therefore, this request is
deemed not 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 PT services have not been met. Therefore, we decided that the Plan does not
have to pre-approve physical therapy (PT) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity percutaneous revascularization for L. Burton.
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 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 the submitted documentation does not support the medical necessity of the procedures in question. Standard of care would limit procedures to those that are medically necessary. There is no documentation of lifestyle-limiting claudication or rest pain in this enrollee. There is documentation that she healed her wounds. There is no documentation of ankle-brachial indices (ABIs) or toe pressures. There is no indication for percutaneous revascularization and intervention in this setting may accelerate her risk of limb loss. The procedure 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 lower extremity percutaneous revascularization for L. Burton.
The Local Coverage Determinations (LCDs) and National Coverage Determination (NCD) referenced by the Plan are not relevant to the services at issue and were not used in the MAXIMUS determination.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride - excluding varnish (D1208)
provided to the enrollee on September 5, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in the enrollee's EOC as a covered benefit;
therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for topical application of
fluoride - excluding varnish (D1208) provided to the enrollee on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 16, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
You asked the Plan to pre-approve these services. You say that the doctor prescribed this medication. The Plan
denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have has
knee pain and a diagnosis of left knee osteoarthritis confirmed by x-rays. The records do not show that you have tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the
required drugs would be less effective or have adverse effects; therefore, Hyalgan is not reasonable or
medically necessary at this time.
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 Hyalgan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) provided on September 25, 2019.
You asked the Plan to pay for the dental service. You say that your claims keep being denied due to a coordination of benefits issue. The Plan denied your request. The Plan says only preventive dental services such as exams, cleanings, periodontal maintenance, and x-rays are covered. The Plan also says that fillings are not a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2391) provided on September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from aggressive rehab services to return home quickly. The Plan denied your request. The Plan says the enrollee is medically stable, and does not need an intensive rehab therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. He has a unilateral left lower extremity impairment without identified significant upper extremity impairment. He is ambulating greater than household distances and performing essential activities of daily living without hands-on assistance and does not require the intensity of an acute level rehabilitation therapy program. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta 32mg injections.
You asked the Plan to pre-approve Zilretta 32mg injections. You say that the requested Zilretta is medically necessary. The Plan denied your request. The Plan says the requested Zilretta is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta 32mg injections. Our reviewer says that the requested Zilretta is not medically necessary. Our physician reviewer found this enrollee presents with a history of chronic right knee pain. He has been diagnosed with severe right knee medial compartment osteoarthritis. Under consideration is a request for Zilretta injections to the right knee. Records document that the enrollee has received Zilretta injections to the right knee on 4 occasions. He reported significant improvement in pain free mobility with prior Zilretta injections. However, the FDA states that Zilretta injections are not indicated for repeat administration as the efficacy and safety has not been demonstrated. Therefore, the documentation does not support that Zilretta is medically reasonable and necessary or safe and effective for treatment of 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 Zilretta 32mg injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta 32mg injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Dexcom G6 continuous glucose monitoring system provided on November 29, 2019.
You asked the Plan to pay for the Dexcom G6 continuous glucose monitoring system billed using codes A9276, A9277, and A9278. You say that the enrollee's physician told you this system was covered. The Plan denied your request. The Plan says continuous glucose monitoring systems are available with plan providers that bill the approved Medicare codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that these codes are not used to bill for supplies used with a covered therapeutic continuous glucose monitor. In this case, the CPT Code Manual definition of code A9276 is sensor, A9277 is transmitter, A9278 is receiver, for use with interstitial continuous glucose monitoring system. We find that the claim was billed with the wrong CPT codes. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pay for the Dexcom G6 continuous glucose monitoring system provided on November 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (01936) provided on June 25, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service was not billed with the appropriate modifier for a repeat procedure.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to substantiate the denial. Therefore, we decided that the Plan has to pay for anesthesia services (01936) provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on September 26, 2019.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on October 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that the lab work was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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 outpatient lab work provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daliresp for the enrollee.
You asked the Plan to pre-approve Daliresp. You say that the enrollee needs this for chronic obstructive pulmonary disease. The Plan denied your request. The Plan says that this is not covered under the member's contract under any normal circumstances.
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 Daliresp for the enrollee.
Benefits for Daliresp 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs assistance getting his strength back. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 22, 2020 with anemia secondary to a gastrointestinal bleed. He is on dobutamine and receiving intravenous (IV) iron. The complexity of his nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. He may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the requested shower chair is not a convenience item for the enrollee but instead is medically necessary. You say that the requested chair is necessary for the enrollee to safely shower because of her age and medical issues. Since she will be moving to a new care facility, she will need her own shower chair. You say that she cannot stand for a shower and the chair keeps her safe and stable. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on March 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab tests. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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 outpatient lab tests provided on March 28, 2019 by an out of network (OON) provider.