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

We decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery.
You asked the Plan to pre-approve sacroiliac joint fusion surgery. You say that the enrollee has failed extensive conservative therapy and pain medications, so it is time to consider surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, as the enrollee has not met testing requirements, did not complete conservative therapy, and did not appear to have a 75% reduction in her pain after treatment of 2 injections.
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 sacroiliac joint fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no recent imaging studies of the sacroiliac joint. There is not documentation of complete physical therapy for sacroiliac joint pain. 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 fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met in a less intensive level of care. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for shortness of breath and lower extremity edema after recent prolonged course of COVID-19 pneumonia. Your medical problems are stable. There are no 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. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was
admitted to the hospital on March 4, 2021, with respiratory failure due to COVID-19 pneumonia. The
anticipated discharge plan was assisted living. The enrollee is working with Physical Therapy and is
ambulating 64 feet with standing rests. The documentation does not support that the enrollee in this case
requires services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no required medical services identified that are available at the LTACH, that are not available at
the current health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus surgery for the enrollee.
You asked the Plan to pre-approve sinus surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for nasal/sinus endoscopic surgery and septoplasty. The Maximus Physician Reviewer determined that sinus endoscopic surgery was medically reasonable and necessary. The reviewer found that the enrollee appeared to be suffering from recurrent acute sinusitis which could warrant endoscopic sinus surgery to help prevent future infections. It was also determined that the requested septoplasty and turbinate reduction was not medically reasonable and necessary. The Plan requested a reopen and stated that the requested turbinate surgery does not require prior authorization and had been approved by the plan. The Plan states that imaging scans did not support a diagnosis of chronic sinusitis. The medical records show the enrollee is a 67-year-old man with a diagnosis of chronic pansinusitis. Previous treatment included steroid nasal spray, antibiotics, and a steroid taper. It is noted that the enrollee's infection continued to return. The physical exam was unremarkable. Imaging from September 18, 2020 shows a right maxillary retention cyst. The paranasal sinuses and nasal cavities were otherwise clear. Our Medical Director concluded that the plan is correct in this case. The computed tomography imaging did not support the diagnosis of chronic sinusitis. The enrollee's condition does not warrant endoscopic sinus surgery to help prevent future infections. Medical necessity has not been established. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sinus surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve sinus surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve MRI services. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says the documentation provided did not include an evaluation of the enrollee's shoulder pain or an explanation for why the MRI is necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI services. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found more clinical information is needed. There is no documentation of a recent trail and failure of physical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the SNF services are medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.

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 the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to
safely and effectively provide medically necessary and reasonable treatment.

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 skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cinacalcet.
You asked the Plan to pre-approve Cinacalcet. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Cinacalcet.
Benefits for Cinacalcet 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: 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 enrollee is with falls and confusion. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a minimal to moderate assist level with functional mobility. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.
You asked the Plan to pre-approve Xiidra. You say that results from using samples have been favorable. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra eye drops.
Benefits for Xiidra 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hysterosonography with and without color flow
doppler.
You asked the Plan to pre-approve a hysterosonography with and without color flow doppler. You say that the
requested hysterosonography with and without color flow doppler is medically necessary. The Plan denied your
request. The Plan says the requested hysterosonography with and without color flow doppler 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 a hysterosonography with and without
color flow doppler. Our reviewer says that the requested hysterosonography with and without color flow
doppler is not medically necessary. Our physician reviewer found there is nothing in the medical record to
indicate that a transvaginal ultrasound has already been done and that a finding needed further evaluation on a
sonohysterogram. There is nothing in the medical record to indicate that there might be a polyp, for example,
like an endometrial biopsy result, that requires evaluation with a sonohysterogram. Therefore, the member
should proceed with a regular transvaginal ultrasound first. The requested hysterosonography is not 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 a hysterosonography with and without color flow doppler have not been met.
Therefore, we decided that the Plan does not have to pre-approve a hysterosonography with and without color
flow doppler.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Knee orthosis (L1833) and suspension sleeve (L2397) provided September 17, 2020.
You asked the Plan to pay for the orthosis. You say that you have determined that the provider has properly billed for all services and this is a computer error on the plan's part. You therefore submit an appeal and request redetermination. The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim.
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, it appears this enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019 to present. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for Knee orthosis (L1833) and suspension sleeve (L2397) provided September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lift chair received on September 13, 2020.
You asked the Plan to pay for the lift chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item received is not a covered benefit when provided by a provider that is not eligible for participate in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the lift chair received on September 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair.
You asked the Plan to pre-approve an extra wide/heavy duty commode chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that an extra wide/heavy duty commode chair is covered for a beneficiary who weighs 300 pounds or more. We looked at the file and Medicare rules. Review of the file does not support that you weigh 300 pounds or more. Based on this information, we decided that Medicare rules for coverage of an extra wide/heavy duty commode chair have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra wide/heavy duty commode chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 14, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045, the transportation of portable x-ray equipment and personnel coded R0070, and the set-up portable x-ray equipment services coded Q0092 provided on September 18, 2020.
You asked the Plan to pay for the x-ray services, the transportation of portable x-ray equipment and personnel, and the set-up portable x-ray equipment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 codes 71045, R0070 and Q0092 are not supported in the medical record. Specifically, codes Q0092 and R0070 have a professional component/technical component indicator of 3. This indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only. Procedure code 71045 needs to be billed with the correct modifier of 26. Based on this information, we decided that Medicare rules for coverage of the x-ray services, the transportation of portable x-ray equipment and personnel, and the set-up portable x-ray equipment services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045, the transportation of portable x-ray equipment and personnel coded R0070, and the set-up portable x-ray equipment services coded Q0092 provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic parenteral drug (D9610).
You asked the Plan to pay for the therapeutic parenteral drug. You say that you cannot afford to pay for this
service out of pocket. The Plan denied your request. The Plan says this service is not covered under your
benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plans coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a
therapeutic parenteral drug (D9610).