Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Device for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these types of systems are unproven and 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 requested services are not considered medically reasonable and necessary in this case. The spacer device is experimental. More research is needed to show the safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit securement package wheelchair accessory (K0108).

You asked the Plan to pre-approve a transit securement package. You say that this component is needed to meet your current medical needs. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose and be appropriate and needed for use inside the home. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature and is for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit securement package wheelchair accessory (K0108).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code
78608).

You asked the Plan to pre-approve the PET scan. You say that without the PET scan the doctor cannot come to
a final diagnosis and it is detrimental to the enrollee's health. The Plan denied your request. The Plan says the
enrollee does not have a condition where Medicare covers PET scans of the brain unless down while enrolled
in a clinical study.

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 PET scan. Our physician reviewer
found the review has determined that the medical records provided do not meet the requirements listed in the
NCD for Medicare coverage.

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 PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve brain imaging, PET; metabolic evaluation (CPT Code 78608).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest, abdomen, and pelvis for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee remains asymptomatic, with no evidence of recurrent, metastatic disease on multiple prior imaging studies.

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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found per the NCCN guidelines for colon cancer, this scan is not indicated for surveillance. A CT scan of the chest to assess non-cancerous mediastinal nodes is not reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest, abdomen, and pelvis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional oral tissue biopsy.

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 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 an incisional oral tissue biopsy.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a
hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient
admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program.

While the medical record documents a need for physical and occupational therapy, it does not document a need
for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a frenulectomy with dental code D7960 provided on November 5, 2020.

You asked the Plan to pay for dental code D7960. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D7960 is not covered under your 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, dental code D7960 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a frenulectomy with dental code D7960 provided on November 5, 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a pulmonary embolus. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the genetic testing (81162 and 81307).

You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this testing is 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 the genetic testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member meets NCCN Guidelines for panel genetic testing including for BRCA and PALB2. BRCA2 has been shown to have an association with melanoma. Having a positive mutation would alter screening recommendations. 

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 genetic testing have been met. Therefore, we decided that the Plan has to pre-approve the genetic testing (81162 and 81307).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup.

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.

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. The Plan covers one crown per
calendar year. Core buildups are not covered.

We looked at the file and the Plan's rules. The file shows that you received two crowns and core buildups. The Plan covered one crown per the supplemental benefit. The second crown is not covered by your supplemental benefit or your medical benefit. Core buildups are not listed as covered benefits. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the crown and core buildup.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional physical therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says ongoing services are not needed to restore or maintain function, or to
prevent deterioration.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional 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 the requested additional therapy is not generally accepted as specific
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and
the documentation does not indicate that the enrollee's functional level requires the unique skills of a
professional therapist to safely and effectively provide treatment, or that the services can be safely and
effectively performed only by a therapist, or under the supervision of a therapist. The enrollee is competent in a
home exercise program. The requested services are not part of a maintenance program, and the specialized
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a
program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve eight additional physical therapy visits for the enrollee.
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 would like reconsideration because the member is a high risk for falling and readmission to the hospital. The Plan denied your request. The Plan says the member can safely receive these services in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 

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 pay for surgical assistant services (29882) provided July 8, 2020.

You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says surgical assistants cannot be paid for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 29882. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services (29882) provided July 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99283, 86328) provided July 12, 2020.

You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 

We looked at the file and Medicare rules. The record does not show the provider was eligible to receive Medicare payment. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99283, 86328) provided July 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment and abutment-supported porcelain fused to metal crown.

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 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 a custom fabricated abutment and abutment-supported porcelain fused to metal crown.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole.

You asked the Plan to pre-approve Pantoprazole. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Pantoprazole.

Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (R0700) provided May 11, 2020.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service was not billed with a valid place of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code R0700 is not supported in the medical record. Specifically, this code has a PC/TC Indicator of 3 and cannot be separately billed for place of service code 31. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (R0700) provided May 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services received minus any cost share requirements.

You asked the Plan to pay for the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services minus any cost share requirements. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services received are not a covered benefit.

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 must follow Medicare rules. The rules also 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.

You received the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services by a contract provider. The file does not show that the Plan provided notice that the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services would not be covered. Under Medicare rules, this means the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services are considered approved by the Plan.

In addition, the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the case file submitted to Maximus was largely incomplete. Maximus requested additional information from the plan with no response. The Plan did not provide reasoning on why this claim was being denied. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the arthrocentesis, fluoroscopic guidance for needle placement, injection services, and low osmolar contrast material services received minus any cost share requirements.

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.