Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant
(D6010), custom fabricated abutment (D6057), abutment supported porcelain/ceramic crown (D6058), and
radiographic/surgical implant index (D6190).
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, abutment supported
porcelain/ceramic crown, and radiographic/surgical implant index. You say that the sales brochure for your
insurance plan did not reflect that the Plan did not cover dental implants. The Plan denied your request. The
Plan says these services are not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057),
abutment supported porcelain/ceramic crown (D6058), and radiographic/surgical implant index (D6190).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and accompanying accessories as defined by codes (K0861, E2361, E1028, E1002, E2300, E0955, E1012, E2377, E2311, E2313, E2607).

You asked the Plan to pre-approve the power mobility device and accessories. You say that the Group 3 power wheelchair was requested in error and you will be submitting another claim with the corrected code. The Plan denied your request. The Plan says they are currently considering the corrected code for approval but has not authorized it yet. The accessories will not be approved as no power mobility device has been authorized.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. Since the corrected code of the power mobility device has not been authorized, the denial of the PMD accessories are upheld as they are not medically necessary or useful by themselves. 

This means that Medicare rules for coverage of a PMD or the accessories for the PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device and accompanying accessories as defined by codes (K0861, E2361, E1028, E1002, E2300, E0955, E1012, E2377, E2311, E2313, E2607).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 19, 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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 modifier to allow for separate payment of the professional component. 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 testing services rendered on October 19, 2020.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for the requested service.

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. Our physician reviewer found that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you are in pain when you have to walk. The Plan denied your request. The Plan says a power operated vehicle is not covered for use outside the home.
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. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Rezum procedure.
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. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has failed medical treatment. Prostatic volume is 43 milliliters. The records provided support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are satisfied. The requested service is recommended. 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 a Rezum procedure.
Local Coverage Determination (LCD) L37808 referenced by the Plan is not valid for the services at issue and was not used in the MAXIMUS determination.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty of one to three teeth (D7321).
You asked the Plan to pre-approve alveoloplasty. You say that you need this before you can get dentures. The Plan denied your request. The Plan says this is not covered.
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 alveoloplasty of one to three teeth (D7321).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) 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 ten (10) 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 since beginning PT, the enrollee, status post right total knee replacement, made progress and lacks endurance and at this stage and skilled therapy is not warranted. Endurance can be built at home rather than with a skilled therapist's intervention. The additional PT visits are not reasonable and not medically necessary. The documentation does not support the need for the requested additional therapy visits. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure is considered safe and effective, and
the enrollee is a good candidate. The Plan denied your request. The Plan says the denial of authorization for
this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show its safety and 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 have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 chronic low back pain and lumbar spinal stenosis. The records indicate that imaging demonstrated multilevel disease but moderate spinal stenosis was reported. The records do not support that the Superion spacer is 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 a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the requested wheelchair is a duplicate service that cannot be 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 the enrollee received a group 3 power wheelchair July 22, 201. The enrollee's current wheelchair serves the same purpose as the requested wheelchair. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomography (CT) of the orbit, sella, or posterior fossa or outer, middle, or inner ear (70480).
You asked the Plan to pre-approve CT of the orbit, sella, or posterior fossa or outer, middle, or inner ear. You say that the service is medically necessary. The Plan denied your request. The Plan says the facility chosen is not in network with the Plan.
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. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT of the orbit, sella, or posterior fossa or outer, middle, or inner ear have not been met. 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 CT of the orbit, sella, or posterior fossa or outer, middle, or inner ear.
Therefore, we decided that the Plan does not have to pre-approve Computed tomography (CT) of the orbit, sella, or posterior fossa or outer, middle, or inner ear (70480).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on October 12, 2020.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you were not informed of the copayment amount prior to receiving the services. You feel that you should only owe a specialist visit 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 $200 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received a spinal canal injection at an ambulatory surgical center on October 12, 2020. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for a spinal canal injection. A spinal canal injection falls 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 a spinal canal injection provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the epidural injections (64484, 64483).
You asked the Plan to pre-approve the epidural injections. You say that the service is medically necessary. The Plan denied your request. The Plan says no more than two epidural injections may be performed at a single session (i.e., single level bilaterally or two levels unilaterally).
The Plan must follow Medicare rules. Medicare rules say that no more than two epidural injections may be performed at a single session (i.e., single level bilaterally or two levels unilaterally). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the epidural injections have not been met. Specifically, the request is for more than the allowed two injections at a single session. This means the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the epidural injections (64484, 64483).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hydromorphon tablet.
You asked the Plan to pre-approve the hydromorphon tablet. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
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 hydromorphon tablet.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auto emersion therapy mattress.
You asked the Plan to pre-approve an auto emersion therapy mattress. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are other treatments options which work well for your condition.
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 an auto emersion therapy mattress. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. The requested mattress exceeds your medical needs and is not the standard of care for your condition. Additionally, the requested mattress has features which exceed your needs such as the Touchscreen TEC-Nology feature and is not medically necessary for wound healing. Our physician reviewer found that your condition does not meet Medicare criteria for an auto emersion therapy mattress. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an auto emersion therapy mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve an auto emersion therapy mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on April 14, 2021.
You asked the Plan to waive the copayment for an office visit. You say that this visit should be written off. 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 $65 copayment for out-of-network physician/practitioner services, including doctor's office visits. You have been asked to pay a $65 copayment for an out-of-network office visit. An out-of-network office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on April 14, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. The enrollee 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.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee