Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen One G3 double battery.

You asked the Plan to pre-approve an Inogen One G3 double battery. You say that the item is necessary. The Plan denied your request. The Plan says your current portable oxygen concentrator has a rechargeable battery. Therefore, the requested item is not covered.

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 portable oxygen concentrator with a rechargeable battery. Therefore, we decided that the Plan does not have to pre-approve an Inogen One G3 double battery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a replacement of gastrostomy tube (43762) performed on February 13, 2021.
You asked the Plan to pay for a replacement of gastrostomy tube. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 43762. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for a
replacement of gastrostomy tube have not been met. Therefore, we decided that the Plan does not have to pay for a replacement of gastrostomy tube (43762) performed on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided February 18, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this 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 dental services provided February 18, 2021, by a provider who has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurosurgery consultation to be provided by an OON provider.

You asked the Plan to pre-approve the OON neurosurgery consultation. You say that the network providers are not able to furnish the services that the enrollee needs. The Plan denied your request. The Plan says the OON provider does not offer any services that cannot be provided by a network neurosurgeon. As such, there is no need for OON referral.

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 a neurosurgery consultation to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Purply skin substitute coded as CPT codes 15275 and 15276
provided to the enrollee on October 2, 2020.

You asked the Plan to pay for CPT codes 15275 and 15276. 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 stated that the medical records do not specifically state the type of application
used for the skin substitute.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for CPT codes 15275
and 15276. The Maximus Physician Reviewer determined that the documentation does not indicate that the
provider prepared or created the site. The site was previously prepared by the amputation billed by another
surgeon. Therefore, CPT code 15004 cannot be recommended. The operative note indicates that Puraply, a skin
substitute was applied to an area of 54 cm2 on the right foot. The elements of 15275 and 15276 are satisfied.
CPT code 15275 and 15276 are recommended.

The Plan requested a reopen and argues that the CPT description requires that the "graft is anchored according
to the individual's choice of fixation" (sutures, staples or steri-strips). No mention of fixation is present in the
operative note. Therefore, CPT codes 15275-59 and 15276-59 cannot be verified. The medical records show
the enrollee is a 58-year-old man with a history of diabetes and peripheral arterial disease, who had a chronic
nonhealing wound on his right lower extremity. The pertinent portion of the operative note documents, "The
surgical preparation was carried out on the right foot 54 cm2 followed by skin substitute placement 54 cm2 this
as performed with Puraply antimicrobial wound matrix as the skin substitute."

Our Medical Director has concluded that the Plan is correct in this case. As the fixation method is not
documented in the medical records, the codes 15275 and 15276 are not substantiated. We looked at this
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of CPT codes 15275 and 15276 have not been met. Therefore, we decided that the Plan does not have
to pay for Purply skin substitute coded as CPT codes 15275 and 15276 provided to the enrollee on October 2,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on March 1, 2021.

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 procedure codes S1015 and S8301 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.

You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary per Medicare.

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 ten (10) additional OT visits. 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate 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 by or under the supervision of a therapist. The documentation does not reveal extenuating factors that require ongoing professional OT or diathermy sessions for this enrollee's condition. The requested services are not part of a maintenance program, are the specialized skill, 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.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional OT visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injection.

You asked the Plan to pre-approve sacroiliac joint injection. 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 follows Medicare rules. Medicare rules say that Sacroiliac (SI) joint injections would be considered medically reasonable and necessary for the diagnosis and/or treatment of chronic low back pain that is considered to be secondary to suspected sacroiliac joint dysfunction. 

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 sacroiliac joint injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of physical therapy or other conservative therapy for SI joint pain. Therefore, at this time, the request is deemed 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 sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided on April 8, 2021.

You asked the Plan to pay for the orthosis. You say that the medical records and doctor's order clearly demonstrate medical necessity for the devices prescribed. The Plan denied your request. The Plan says there is evidence of misrepresented services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery, or a delivery ticket. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided on April 8, 2021.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for osteomyelitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: 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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 admission to a SNF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-four (24) additional PT visits.
You asked the Plan to pre-approve twenty-four (24) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 twenty-four (24) additional PT visits.
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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate 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 by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program and her deficits are not so significant that she requires the approval of eighteen (18) more formal therapy sessions or without the outcome of the prior authorized therapy. The requested services are not part of a maintenance program, are the specialized skill, 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eighteen (18) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eighteen (18) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on September 4, 2020.
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 procedure code 00144 is not supported.
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 00144 is anesthesia for procedures on eye; corneal transplant. We find that CPT code 00144 is not supported in the medical record. Specifically, there is no documentation of anesthesia for procedures on the eye. 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 pay for the anesthesia services rendered on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 11, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require are called custodial care and custodial care is not a covered benefit under Medicare or the Plan.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.

You asked the Plan to pre-approve these services. You say that this procedure will greatly increase the enrollee's quality of life. The Plan denied your request. The Plan says that this is contraindicated for the enrollee.

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 requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the gym membership for calendar year 2021.

You asked the Plan to pay for gym membership. You say that you would like reconsideration because you are using the same application process that you have in previous years. The Plan denied your request. The Plan says that you have exhausted your benefit for 2020.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan offers a $150 gym benefit allowance once per calendar year. 

The Plan's rules for coverage of gym benefits have been met because the Plan is responsible to cover a $150 allowance for your membership in 2021. The documentation submitted shows that you have paid over $150 for calendar year 2021. Additionally, the record indicates that you have not used your $140 allowance for 2021 so we must find in your favor. Therefore, we decided that the Plan has to pay for the gym membership for calendar year 2021.

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.