Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additional physical therapy visits.You asked the Plan to pre-approve4 additional physical therapy visits. You say that the utilization of skilled manual therapy gives her the ability to return to the greatest functional level and independence.The Plan denied your request. The Plan says additional visits are 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 4 additional physical therapy 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 enrollee has had extensive therapy for this condition and has been instructed in a home exercise program.Our reviewer says thatthe unique skills of a professional therapist are not required to safely and effectively provide ongoing 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 4 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spinal Cord Stimulator (CPT Code 63685 and 63655). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says Medicare will not cover the spinal cord stimulator placement. 
 
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 criteria for the stimulator are not met. There is no psychological evaluation documented. More 
information is needed. 
 
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 Spinal Cord Stimulator (CPT Code 63685 and 63655).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Sarclisa. 
 
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 that the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has multiple myeloma 
treated with multiple regimens, including Lenalidomide and two proteosome inhibitors. He had a reaction to 
Pomalidomide and is considered allergic to it. Sarclisa will be started with Dexamethasone. The use of Sarclisa 
is FDA approved for use in combination with Pomalidomide and Dexamethasone, for the treatment of adult 
patients with multiple myeloma who have received at least two prior therapies including Lenalidomide and two 
proteasome inhibitors. Lenalidomide is a drug in the same class as Pomalidomide. It is reasonable and 
medically necessary to substitute Lenalidomide for Pomalidomide, given the enrollee's allergy to 
Pomalidomide. The services are therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve Sarclisa.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis. 
 
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 enrollee has low back pain. There is 
no documented spinal instability. Fusion for degenerative low back pain without instability is considered 
experimental in nature and not likely to be effective. The services are therefore 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 arthrodesis.  
 
Local Coverage Determination (LCD) L36000 referenced by the Plan is for the wrong jurisdiction and was not 
used in the MAXIMUS determination.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 18, 2019. 
 
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 95941 is not payable. 
 
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. The provider submitted a claim for procedure code 95941. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the testing services rendered on November 18, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (CPT Code K0554). 
 
You asked the Plan to pre-approve the DME. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
  
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 the DME. Our physician reviewer 
found there is insufficient data to indicate why the patient needs dexcom g6 and could not use the freestyle 
Libre 2 which has alerts for high and low BGS; The freestyle Libre 14-day system does not have alerts but the 
Libre 2 which has been out now for a few months. The Libre 2 needs to be used with the reader and not with a 
phone so if there is a reason why the patient cannot carry the reader with her, then the dexcom would be 
medically necessary as it provides alerts/alarms for high or low BS directly to a smart phone. There is no data 
provided here to indicate that the patient cannot carry the reader and hence, there is insufficient data to prove 
that the patient needs the DEXCOM g6  instead of the Libre 2. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT 
Code K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) tooth # 28. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. 
The Plan denied your request. The Plan says core build up is not listed as 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 requested items or services are not 
among those covered under this benefit. The Customer Handbook specifically states that core build up is 
excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve core build up 
(D2950) tooth # 28.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 9, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this testing was ordered by telemedicine which is a Medicare prohibited action.

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 laboratory testing provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on April 4, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this member has previously received the same item from a different provider on June 5, 2018.

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 rules also say that in no case can the reasonable useful lifetime of DME be less than 5 years.

The file shows thatthe enrollee received lumbar-sacral orthosis on June 5, 2018. The additional lumbar-sacral orthosis at issue, was received within the reasonable lifetime time-frame. There is no indication in the record that a replacement of the initial brace was reasonable and necessary due to loss or irreparable damage. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on April 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination provided on June 23, 2020.

You asked the Plan to pay for routine eye exam. You say that you had problems with your vision and went to get your eyes checked. The Plan denied your request. The Plan says the denial of payment for this service is correct, because you had already received a covered routine eye exam within the previous 2 years.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a routine eye examination once every 2 years.

We looked at the file and the Plan's rules. You had a previous routine eye exam on April 18, 2019, therefore the benefit for this service was exhausted for this date of service. Based on this information, we decided that the Plan's rules for coverage of routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination provided on June 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for glycosylated hemoglobin (A1C) testing provided on November 21, 2019. You asked the Plan to hold you harmless for lab test. You say that you feel this service was medically necessary and it was ordered by your treating provider. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not payable by Medicare under the circumstances. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. This testing was performed by an in-network laboratory. The file does not show that the Plan provided notice that lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for glycosylated hemoglobin (A1C) testing provided on November 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided.

You asked the Plan to pay for the ambulance services. You say that this claim is not a duplicate and should be paid. The Plan denied your request. The Plan says the ambulance service was approved for the allowed amount and the enrollee's copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $270 copayment for ambulance services. 

The enrollee has been asked to pay a $208.83 copayment for the ambulance services. The ambulance services fall within the ambulance services benefit category. The allowed amount is $208.83. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit and related services (G0463, 77063, 77067) provided on June 30, 2020.

You asked the Plan to waive the copayment for the hospital outpatient clinic visit and related services. You say that you disagree with the copayment as charged as you do not remember a copayment being required in the past. The Plan denied your request. The Plan says the copayment applied correctly in this case.

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 $20 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $20 copayment for the hospital outpatient clinic visit and related services. The services fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 the hospital outpatient clinic visit and related services (G0463, 77063, 77067) provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen for treatment related to 
metabolic syndrome, hyperlipidemia, elevated CRP, and Vitamin D deficiency. The Plan denied your request. 
The Plan says naturopath services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the medical services provided.
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 you have spinal cord damage and a broken right hip. 
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 submitted records show that you were 
admitted to the hospital on November 17, 2020 with a hip fracture after a fall. You underwent surgical repair 
on November 18, 2020. You need maximum assistance to sit up and stand up. You do not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of 
rehabilitative services and regular physician evaluation. The services are therefore 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the insertion of a catheter provided on 
September 18, 2019. 
 
You asked the Plan to waive the copayment for the insertion of a catheter. You say that you disagree with the 
charges because the first insertion did not work and you should not owe a second 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $325 copayment for the insertion of a catheter. The insertion of a catheter falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 the insertion of a catheter 
provided on September 18, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for CT Scan(73700) of a lower extremity provided on July 11, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because a modifier 
cannot be added to this service. The Plan denied your request. The Plan says that this procedure was billed 
without the appropriate anatomical modifier. 
 
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 73700 is computed tomography, lower extremity; without contrast material  
We find that CPT code 73700 is supported in the record. Specifically, the billed service is for the professional 
interpretation of the CT Scan. The record does not indicate a specific side to show laterality. Based on this 
information, we decided that Medicare rules for coverage of the CT Scan have been met. Therefore, we decided 
that the Plan has to pay for CT Scan(73700) of a lower extremity provided on July 11, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on January 14, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the claim was submitted timely to other 
insurance. The Plan denied your request. The Plan says the claim was untimely 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you 
to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
radiology services until the primary insurer has denied the claim for these services. You have 1 year from the 
 
 
date of service to then submit the claim to the Plan. Therefore, we decided that the Plan does not have to pay 
for the radiology services provided on January 14, 2020.