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

We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).

You asked the Plan to pre-approve the HBOT. You say that you are confined to a wheelchair and cannot walk or stand. You say that you have wound care treatments done 3 times per week and you go to the doctors at least 2-3 times per month. You say that you are fearful of losing your right leg because you are being denied treatment that could help health the wounds. You say that you cannot continue compression therapy right now because the wounds cause great discomfort. You say that the requested HBOT would enable you to return to some normalcy in your life. The Plan denied your request. The Plan says that the enrollee's diagnosis is not a covered condition for HBOT.

The Plan must follow Medicare rules. Medicare rules say that HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. Medicare rules say that items or services will be covered when 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 the HBOT. Our reviewer says that HBOT is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has non-healing venous stasis ulcers that have failed quite extensive conventional therapy. The enrollee is at risk for limb loss. HBOT is beneficial in therapy for non-healing wounds due to inadequate perfusion. 

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 HBOT have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care can be provided safely at a less intensive setting 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. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
COVID-19 pneumonia and respiratory failure. 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.

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception to see an out-of-network
dentist.

You asked the Plan to pre-approve the dental service. You say that you have been seeing this dentist for over 5
years. You say that he is now an out-of-network provider. You say that you would prefer to keep him as your
dentist. You say that you would like a single patient agreement. You also say that there are not many dentists in
your area. The Plan denied your request. The Plan says there are in network dentists available in your area. The
Plan also says that you can elect to use your out-of-network benefits to continue seeing this dentist.

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 and out-of-network dental services are
covered, there are in-network dentists available to see you. Therefore, we decided that the Plan does not have to
pre-approve an in-network exception to see an out-of-network dentist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.

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 care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve flow cytometry (88189, 88184, 88185).

You asked the Plan to pre-approve flow cytometry. You say that the flow cytometry is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that flow cytometry is covered when 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 flow cytometry. Our reviewer says that
the requested testing is not medically necessary. Our physician reviewer found the enrollee had an absolute
lymphocyte count of 2900 with a normal white blood cell count making the likelihood of CLL low. In addition,
only one suspicious node was seen and noted to be smaller than on prior imaging and likely secondary to a
history of gastritis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of flow cytometry have not been met. Therefore, we decided that the Plan does not
have to pre-approve flow cytometry (88189, 88184, 88185).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced leg pump device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there was no four week trial of a basic device.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee has unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a four week trial and failure of a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced leg pump device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an additional 300 test strips (A4253, A4259).
You asked the Plan to pre-approve the additional strips. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no clinical documentation to support the need for a high utilization.
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the additional strips. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you were advised to check four times a day on your prescription prior to insulin shots. Your a1c is low at 5.9% suggesting that you may be having low blood glucose levels. Instead of the standard 3 times a day, due to concerns over low blood glucose levels, it is reasonable to cover this four times a day. 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 additional strips have been met. Therefore, we decided that the Plan has to pre-approve an additional 300 test strips (A4253, A4259).
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 breast tomosynthesis (77063) provided on November 25,
2020.

You asked the Plan to pay for breast tomosynthesis. You say that this is supported in the records. The Plan
denied your request. The Plan says this is an add-on code.

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 77063 is screening digital breast tomosynthesis, bilateral
(List separately in addition to code for primary procedure).

We find that CPT code 77063 is not supported in the medical record. Specifically, this code was not billed with
a primary procedure. Based on this information, we decided that Medicare rules for coverage of breast
tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast
tomosynthesis (77063) provided on November 25, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a SPECT/CT.
You asked the Plan to pre-approve a radiopharmaceutical localization of tumor, inflammatory process or
distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed);
tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for
anatomical review, localization and determination/detection of pathology, single area (e.g., head, neck, chest,
pelvis), single day imaging (78830). You say that the enrollee needs this radiology procedure. The Plan denied
your request. The Plan says that the medical records do not support medical necessity for the SPECT/CT.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 radiopharmaceutical localization of
tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood
pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT)
transmission scan for anatomical review, localization and determination/detection of pathology, single area
(e.g., head, neck, chest, pelvis), single day imaging (78830). Our reviewer says that the service is reasonable
and medically necessary. Our physician reviewer found that in this case, a CT scan does not show a fluid
collection but does demonstrate lymphadenopathy. The hardware appears intact. Aspiration yielded a culture of
Corynebacterium. The SPECT/CT to differentiate recurrent lymphoma from infection is medically necessary
and reasonable prior to a decision as to whether to remove the hardware. 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 a radiopharmaceutical localization of tumor, inflammatory process or
distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed);
tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for
anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest,
pelvis), single day imaging (78830) have been met. Therefore, we decided that the Plan has to pre-approve a
SPECT/CT.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onivyde (J9205) for the enrollee.

You asked the Plan to pre-approve Onivyde (J9205). You say that Onivyde (J9205) 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 the Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Onivyde (Irinotecan liposome). The Maximus Physician Reviewer determined that the requested drug is medically reasonable or necessary. Our physician reviewer found the medical records provided evidence that the use of this medication was medically necessary by the requesting provider. Given the failure of other means of palliation, it is medically reasonable to try this as palliative therapy. The Plan argues that there is no established evidence to support the use of single-agent Onivyde for metastatic high-grade neuroendocrine tumor of unknown primary. The records show the enrollee has a diagnosis of extensive high-grade neuroendocrine carcinoma of unknown primary, with computed tomography evidence of disease progression. Our Medical Director has concluded that the Plan is correct in this case. The use of Onivyde (Irinotecan liposome) for the treatment of high-grade neuroendocrine carcinoma is not supported by the compendia or by documentation in the medical literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onivyde (J9205) have not been met. Therefore, we decided that the Plan does not have to pre-approve Onivyde (J9205) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are growing weaker every day since you were
discharged to home from the hospital. You say that you have no strength to go to and from the bathroom and
you have lost a lot of weight. The Plan denied your request. The Plan says based on Medicare guidelines, the
IRF services you and/or your provider are requesting do not meet the requirements for approval for IRF
admission from home.

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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted to
the hospital for osteomyelitis of the toe, and you were discharged home after surgery. You have ongoing 
weakness. 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.

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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress (E0303).

You asked the Plan to pre-approve the heavy-duty hospital bed. You say that you do not fit in regular beds because of your height. You are suffering from a lot of pain and just had a stroke, and your condition is fragile because of it. You need this for better quality of life. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a heavy-duty hospital bed due to the weight of 233 pounds.

The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met:

1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 

3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 

4. The patient requires traction equipment, which can only be attached to a hospital bed.

We looked at the file and Medicare rules. In this case you do not meet the Medicare weight limit of 350 to 600 pounds for the requested item. The records show that you weigh 233 pounds. Based on this information, we decided that Medicare rules for coverage of the heavy-duty hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress (E0303).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a
participating provider on November 5, 2020.

You asked the Plan to waive the copayment for emergency room services. You say that you do not know why
you are being charged this copayment. The Plan denied your request. The Plan says the correct copayment has
been 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). Your contract with the Plan clearly says that you must pay a $100
copayment for emergency care.

You have been asked to pay a $100 copayment for emergency room services. The correct copayment has been
applied to the services that were provided. Emergency room services fall within the emergency care 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 emergency room services provided by a
participating provider on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve the system. 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 say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).