Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET/CT imaging.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that there has been no biopsy or face-to-face exam done.
The Plan must follow Medicare rules. Medicare rules say that PET 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 the imaging. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found you have two pathological fractures, one of the left hip, and most recently of the left rib. Work-up to date has been negative and pathology was not sent from hip surgery. A PET scan is requested to determine the optimal anatomic location for an invasive procedure (biopsy) and the to determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. The service is 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 the imaging have been met. Therefore, we decided that the Plan has to pre-approve PET/CT imaging.
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 provide additional payment for the frames (V2020) and diagnostic imaging of retina (92227) provided October 27, 2020 and the frames (V2020), progressive lens (V2781), vision item or service, miscellaneous (V2799), sphere, single vision (V2100), and anti-reflective coating (V2750) provided November 17, 2020.
You asked the Plan to provide additional payment for the frames, diagnostic imaging, progressive lenses, miscellaneous vision item or service, single vision sphere and anti-reflective coating. You say that you should be due additional reimbursement. The Plan denied your request. The Plan says the copayment for the photos
taken during an eye exam was charged correctly, only one set of frames is covered and the frames and lens package was processed correctly as an out-of-network service.
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 one pair of eyeglasses per calendar year up to a $200 benefit when provided by a network vision provider. The Plan does not cover diagnostic imaging of retina. We looked at the file and the Plan's rules. In this case you purchased frames and lenses from an out-of-network (OON) provider. The Plan provided documentation that the entire contracted rate was covered by the Plan and $120 vision benefit was applied. Since the eyeglasses were purchased OON, the provider is allowed to bill you for the difference between the Plan's contracted rate and the total amount that was charged by the OON provider. Since the Plan applied the vision benefit to this pair of eyeglasses, another set of frames is not covered by the Plan. Finally, although the Plan has supplemental vision benefits including routine eye exams, the diagnostic imaging of retina is not listed as a covered service under the vision benefit. Based on this information, we decided that the Plan does not have to provide additional payment for the frames (V2020) and diagnostic imaging of retina (92227) provided October 27, 2020 and the frames (V2020), progressive lens (V2781), vision item or service, miscellaneous (V2799), sphere, single vision (V2100), and anti-reflective coating (V2750) provided November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise
specified, all-terrain upgrade (K0108).
You asked the Plan to pre-approve the all-terrain upgrade. You say that the medical record provided clearly
proves the enrollee qualifies for a group 3 power wheelchair with tilt, recline and other accessories. Therefore,
you request the denial of the authorization to be reversed. The Plan denied your request. The Plan says this is a
non-medical feature that is intended for use outside of the home. This item is not considered DME and is not
covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the all-terrain upgrade have not been met. Therefore, we decided that the Plan does not have to preapprove
wheelchair component or accessory, not otherwise specified, all-terrain upgrade (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).

You asked the Plan to pre-approve the dentures. You say that the dentures you had made were done so poorly that they are affecting your health and day-to-day life. Your current dentures are painful to wear. The Plan denied your request. The Plan says dentures are not covered by Medicare and are only covered by the Plan once every five years. You had your last set of dentures made less than five years ago.

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 dentures are requested in a frequency that is greater than what is allowed by the Plan. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the criteria for coverage of a therapeutic CGM are not met and the services are not medically necessary; however, no medical records were received with the case file. Maximus requested records from the Plan, but a response was not received. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 a custom fabricated abutment (D6057) and abutment
supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain/ceramic
crown. You say that you would like these services to be approved for coverage. The Plan denied your request.
The Plan says these services are not covered under your benefit 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
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).

You asked the Plan to pre-approve a partial denture. You say that you need this denture. The Plan denied your request. The Plan says partial dentures are not covered by Medicare or by the Plan's supplemental dental benefit.

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 partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the coverage criteria is not met.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not taking insulin, so the criteria is not met. Although you complain of symptoms of low blood sugar levels, you are not on a medication that causes low blood sugar. The records do not show show low blood sugar on a meter. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered for the indication listed in the applicable LCD.

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 epidural steroid injection. Our reviewer says that the requested epidural steroid injection is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 75-year-old man with chronic low back pain. He has multi-level degenerative disc disease with disc protrusions and foraminal stenosis. This meets the LCD criteria. The requested injection is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must use network providers to get medical care and services when there are network providers available. The only exceptions are emergencies and urgently needed services when the network is not available (generally, when you are out of the area) and out -of -area dialysis services. You should always confirm authorization requirements before receiving services.

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.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 26, 2018.

You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed within the time allotted per Medicare criteria.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the physician services was not filed until January 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services provided on November 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum socket system for a prosthetic leg.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of unusually harsh environmental situations.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician documentation does not support that you require a vacuum assisted socket. Additionally there is no evidence that you are exposed to harsh environmental conditions that require a L5962 prosthetic cover. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum socket system for a prosthetic leg.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy evaluation for the enrollee with an out-of-network provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.

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. 

The requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve a physical therapy evaluation for the enrollee with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no qualifying diagnosis that is causing a mobility limitation.

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.

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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found while the
enrollee may have the cognition to use a power wheelchair the documentation does not support that he requires
the requested Group 3 power wheelchair. The enrollee does not have a Myopathy, congenital skeletal
deformity, or a neurologic diagnosis. The physician physical exam findings are not consistent with paraplegia
such as seen with a true spinal cord injury diagnosis. As the enrollee does not qualify for the Group 3
wheelchair base, none of the requested accessories are 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 the wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).

You asked the Plan to pre-approve an oxygen concentrator. You say that you need this due to your chronic obstructive pulmonary disease. The Plan denied your request. The Plan says you have not had a blood gas study.

The Plan must follow Medicare rules. Medicare rules say that home oxygen therapy is reasonable and necessary only if the beneficiary has had a qualifying blood gas study. 

We looked at the file and Medicare rules. The records do not show that you have had a blood gas study. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Arthrocentesis (20611) provided on November 12, 2020.

You asked the Plan to pay for Arthrocentesis. You say that this code is documented in the records. The Plan
denied your request. The Plan says the records do not show that ultrasound guidance was performed.

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 20611 is Arthrocentesis, aspiration and/or injection, major
joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent
recording and reporting.

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 Arthrocentesis. Our reviewer says that this
code is not supported. Our physician reviewer found the procedure report does not include documentation to
support ultrasound guidance and permanent recording.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Arthrocentesis have not been met. Therefore, we decided that the Plan does not
have to pay for Arthrocentesis (20611) provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology evaluation to be provided by an out of network provider.

You asked the Plan to pre-approve an ophthalmology evaluation with and out-of-network provider. You say that the enrollee needs care outside the state as there are no trained specialists in the state for the enrollee's condition. The Plan denied your request. The Plan says there are in network providers available to meet the enrollee's medical needs.

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. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an ophthalmology evaluation to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).

You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and core build up for tooth 12.

You asked the Plan to pre-approve these services. You say that the services are necessary. The Plan denied
your request. The Plan says the services are not covered benefits.

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 Plan covers crowns represented by codes D2750 to D2753 only.
Therefore, we decided that the Plan does not have to pre-approve a crown and core build up for tooth 12.