Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. 
 
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 long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has very limited mobility and they 
are in pain that is affecting all aspects of daily activity. The Plan denied your request. The Plan says the request 
is not medically necessary because the enrollee's records show they do not have documentation of this degree 
or duration of improvement in the enrollee's pain and function after the enrollee's previous rhizotomy 
procedures. 
 
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 physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage, 
specifically there is no documentation that the patient experienced greater than or equal to 50% improvement 
of pain and improvement in patient specific ADLs documented for at least six months after prior 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT Code 64635).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor.
You asked the Plan to provide coverage for a continuous glucose monitor. You say that a continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not
met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply
the correct LCD criteria.
Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is
coverage for a continuous glucose monitor (CGM). The Maximus Physician Reviewer determined that the
Medicare rules for coverage for this device were met. The Plan requested a reopen and stated that all of the
required coverage criteria stated in the LCD are not met. The medical records state that you have a diagnosis of
type 2 diabetes mellitus with hyperglycemia. On August 25, 2020 the medical records show you saw the
endocrinologist and there was a recent change in your insulin to 70/30 twice daily. The notes indicate that your
diabetes was under control. The Current Medications list includes Novolin R to be used as directed.
However, the medical records and physician notes do not clearly document exactly how many daily injections
of insulin you are received as you are using 35 to 40 units of 70-30 insulin twice daily, and Novolin R was on
her medication list to be used only as directed. The coverage criteria for a CGM states "The beneficiary is
insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous
subcutaneous insulin infusion (CSII) pump." The medical records do not demonstrate that you meet all of the
required criteria stated in the LCD for coverage for this device. 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 continuous
glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide coverage for
a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left shoulder magnetic resonance imaging (MRI) 
(73221). 
 
You asked the Plan to pre-approve a left shoulder MRI. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not had an x-ray or conservative treatment. 
 
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 a left shoulder MRI. Our reviewer says 
that the criteria for coverage of the requested MRI have not been met. Our physician reviewer found there is no 
evidence that the enrollee has undergone a radiographic evaluation of the left shoulder prior to the request for 
the MRI. Moreover, there are no comprehensive clinical findings involving the left shoulder that would 
necessitate advanced diagnostic imaging such as MRI. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to the 
guidelines. Therefore, the requested left shoulder MRI is not 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 a left shoulder MRI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left shoulder magnetic resonance imaging (MRI) (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oscillating hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. Oscillating hospital beds are statutorily not covered as they are not appropriate for use inside the home. Durable medical equipment can only be covered when it is needed inside the home. Therefore, we decided that the Plan does not have to pre-approve an oscillating hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470) and local anesthesia in 
conjunction with operative or surgical procedures (D9215). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says diagnostic cast is not listed as a covered service. The Plan says that local 
anesthesia is not listed as a covered service either. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
diagnostic casts (D0470) and local anesthesia in conjunction with operative or surgical procedures (D9215).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 outpatient day institute visits.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee no longer requires all three therapy modalities concurrently in an intensive setting.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 the requested services. Our physician reviewer found that the requested services exceed yourmedical needs. You donot have speech or swallowing deficits. Yourlevel no longer requires all 3 modalities of physical, occupational, or speech therapy in an intensive level such as an outpatient day institute for rehab 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve10 outpatient day institute visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device (22869) (Vertiflex device).
You asked the Plan to pre-approve a Vertiflex device. You say that the device is medically necessary. The Plan
denied your request. The Plan says the device 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 Vertiflex device. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the device is experimental and there is not enough information on its safety or
efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex device have not been met. Specifically, there is not information on the
devices safety and efficacy making this device not reasonable or necessary for the enrollee's diagnosis.
Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device (22869) (Vertiflex device).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT 99233) provided to the enrollee on July 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this may only be reported once per day.
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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient." We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider billed, and was reimbursed for CPT 99233 for date of service July 9, 2020, claim number 820202160062064. If an additional claim with same procedure code on same date of service by same provider is submitted, this payment would be considered a duplicate payment, and therefore, not reimbursable. We looked at this coder'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 pay for subsequent hospital care (CPT 99233) provided to the enrollee on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Donepezil tablets. 
 
You asked the Plan to pre-approve the Donepezil tablets. You say that the enrollee is experiencing memory 
loss, and you feel this drug is medically necessary. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
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 the Donepezil tablets.  
 
Benefits for the Donepezil tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (CPT 76498)provided to the enrollee on June 1, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 76498 (1 unit) remains 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 76498 is "Unlisted magnetic resonance procedure (eg, diagnostic, interventional)."We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the radiology report did not include documentation of an unlisted procedure.  When reporting an unlisted procedure code, documentation should include what the unlisted procedure code is to confirm services were performed.We looked at this coder'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 pay forradiology services (CPT 76498) provided to the enrollee on June 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contractsays that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $35 copaymentfor urgently needed servicesat an in-network urgent care center. You can find this information on pages 92 to 93of the Plan's 2020 EOC.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee's ongoing rehabilitative needs warrant this level of care to achieve a safe and sustainable discharge.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgery for invasive squamous cell carcinoma. Hospital course was complicated by respiratory failure and pulmonary edema. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupationaltherapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe continuation of inpatient mental health care after January 7, 2021.You asked the Plan to pay forthe continuation of inpatient mental health care. You say that inpatient mental health care is still necessary for the enrollee.The Plan denied your request. The Plan says additional inpatient mentalhealth care is not medically necessary and lower level of care would be appropriate.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 the continuation of inpatient mental health care. Our reviewer says that the service is not medically necessary. Our physician reviewer found this enrollee does not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It does notappear that active treatment was taking place beyond the date in question. It does not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. It appears that the enrollee can be treated in a lesser restrictive 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 the continuation of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forthe continuation of inpatient mental health care after January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on August 27, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that you must receive 
your care from a network provider. In most cases, care you receive from an out-of-network provider will not be 
covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network 
cannot provide this care, you can get this care from an out-of-network provider. You or your PCP must obtain 
authorization from the plan prior to seeking care. 
 
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 and the referring provider in this case are not network providers with the Plan. The Plan 
did not pre-approve the drug test. 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 a drug test provided on August 27, 2020.
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 this is medically necessary. The Plan denied 
your request. The Plan says this is not covered by Medicare. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on August 5, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the charges because the mammogram should be covered without a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for non-radiological diagnostic tests. A screening mammogram is covered once every 12 months. The record shows that you received a screening mammogram on July 17, 2020. Therefore, the mammogram you received on August 5, 2020, is considered diagnostic, not preventative, and you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on August 5, 2020.