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

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan Euflexxa for the enrollee. You say that Euflexxa is medically necessary for the enrollee.
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 that Maximus did not apply the correct LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for a
drug or biological only if it is safe and effective and otherwise reasonable and necessary. Medicare has specific
coverage criteria for this type of injection which states the enrollee must have failed at least three months of
conservative therapy. Conservative therapy is defined as: Nonpharmacologic therapy (such as but not limited to
home exercise program, education, weight loss, physical therapy if indicated); and if not contraindicated,
simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product prescribing information. The
medical records provided do not specifically document that these criteria were met. Maximus did not address
the LCD when the original decision was made. Therefore, we decided that the Plan does not have to preapprove
Euflexxa for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are considered experimental and 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 is not medically 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 services have not been met.

Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 22, 
2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were in pain and have 
several teeth that need to be pulled. You say that you cannot afford this. The Plan denied your request. The 
Plan says a comprehensive oral evaluation is only covered once every three years. 
 
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, a comprehensive oral evaluation is 
only covered once every three years. The Plan paid for a comprehensive oral evaluation provided on March 24, 
2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation provided on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (22842) provided on June 23, 2020. 
 
You asked the Plan to pay for the services. 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. 
 
We find that coverage of CPT code 22842 is not supported in the medical record. Specifically, code 22842 is 
an add-on code. Add-on codes must be reported with appropriate primary procedure code. In this case, code 
22842 was not reported with an appropriate primary procedure code. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the services (22842) provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp and a tub stool for the enrollee.
You asked the Plan to pre-approve a wheelchair ramp and a tub stool. You say that the tub stool is needed for safety and the wheelchair ramp is required to leave the house. The Plan denied your request. The Plan says these items are not covered by Medicare.
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 rules say that shower equipment is not covered by Medicare. Although these items may be helpful, neither Medicare nor the Plan covers the requested equipment. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp and a tub stool for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture, one or more needles, with electrical stimulation, each additional 15 minutes (97814).
You asked the Plan to pre-approve acupuncture services. You say that you are dealing with severe nerve pain between your shoulders caused by repetition of hands. You have had acupuncture in the past which helps a lot and you do not understand how the Plan can make this decision. The Plan denied your request. The Plan says acupuncture is only covered for the treatment of chronic lower back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, your request is for pain in your shoulders. Therefore, we decided that the Plan does not have to pre-approve acupuncture, one or more needles, with electrical stimulation, each additional 15 minutes (97814).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999), and an unspecified periodontal procedure (D4999) provided from October 8, 2020, through October 9, 2020.
You asked the Plan to pay for an unspecified adjunctive procedure, and an unspecified periodontal procedure. You say that the services at issue were necessary. The Plan denied your request. The Plan says the services at issue 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. Therefore, we decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999), and an unspecified periodontal procedure (D4999) provided from October 8, 2020, through October 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on December 7, 2020.

You asked the Plan to pay for the subsequent hospital care. You say that hospice was revoked on December 5, 2020; therefore, the patient was not enrolled in hospice. You say that the documentation should be reviewed, and the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on December 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician ordered specialized 
testing for this patient. You say that you do not have direct patient contact you only perform the testing 
services. The Plan denied your request. The Plan says Original Medicare is responsible for payment. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs or skilled therapy 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an echocardiogram to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an echocardiogram. You say that your doctor wishes you to have the
services at the out-of-network provider so they will be present. The Plan denied your request. The Plan says the
requested services can be provided by a network provider.
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
an echocardiogram to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture with a metal and resin base (D5213) 
provided on March 4, 2021. 
 
You asked the Plan to pay for the denture. You say that you should be reimbursed for this denture as a covered 
service. The Plan denied your request. The Plan says this specific type of denture is not covered by your dental 
benefit. In addition, a Notice of Denial of Medical Coverage was issued in January 2021, when this denture 
was first requested. 
 
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 denture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper 
denture with a metal and resin base (D5213) provided on March 4, 2021.
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 the enrollee needs intense rehabilitation. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs 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 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. 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 back pain and compression fractures after a fall and was discharged home on August 18, 2021. The enrollee's medical
problems are stable. 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 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee has multiple disabilities that makes a shower chair medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) provided on February 26, 2021.
You asked the Plan to pay for progressive lenses. You say that you should not have to pay anything. The Plan denied your request. The Plan says the full package allowance for the frame and lens services was exhausted by your lens purchase.
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 these services when The Plan contract says that you have a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses, once per calendar year. The benefit can only be used one time. Any remaining benefit dollars do not roll over to a future purchase. We looked at the file and the Plan's rules. The records show that you exhausted your maximum benefit allowed amount on February 26, 2021. The records also show that you will be eligible for frames, lenses and/or contacts on January 1, 2022. Based on this information, we decided that the Plan's rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 20, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this limited oral evaluation to replace your second preventive dental exam. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not purchase the optional supplemental benefits which allows two limited oral evaluations per calendar year.
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 pay for the problem focused limited oral evaluation (D0140) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96413) provided on March 23, 2021.

You asked the Plan to pay for chemotherapy administration. You say that the enrollee received a Reclast infusion for one hour. The Plan denied your request. The Plan says there is a more appropriate code for this 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. 

In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. 

We find that CPT code 96413 is not supported in the medical record. Specifically, the records show that the enrollee received a Reclast infusion. Reclast is not a chemotherapy drug. There is a more appropriate code for the service performed. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413) provided on March 23, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for pharmacogenomic testing (code 81479) provided on February 17, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and must be paid at the established rate. The Plan denied your request. The Plan says that this testing is not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for genetic testing by a contract provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for pharmacogenomic testing (code 81479) provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a F-22 rollator walker/upright walker for the enrollee. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says a walker was received less than five years ago. 
 
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 walker. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal a detailed objective  physical examination of the enrollee. The medical 
progress notes do no indicate that the requested device would be more beneficial than a standard walker. There 
is no objective evidence that the enrollee would be able to safely use the requested device. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a F-22 rollator walker/upright walker for the enrollee.