Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation (RFA) of the sacroiliac (SI) joint.You asked the Plan to pre-approvethese services. You say that the procedure will help physically and financially.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have had two previous SI joint injections with 80 percent pain relief. The request is for RFA of the SI joint. This procedure is considered experimental/investigational in nature due to wide variation of effectiveness. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Group 3 power wheelchair upgraded electronics.
You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller
harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 3 power
wheelchair, accessories and upgraded electronics. The Plan denied your request. The Plan says the upgraded
electronics are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is
medically necessary.
Documentation shows that the enrollee has normal range of motion and strength in the bilateral upper limbs.
Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options
using their own switches which are included in the allowance of these power options.
This means that Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided
that the Plan does not have to provide Group 3 power wheelchair upgraded electronics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you need to progress.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admissionis 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 medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital with facial fractures after a fall, weakness, and COVID-19 infection. Your medical conditions are now stable,and you have 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 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 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to provide coverage fora positron emission tomography (PET) scan for the enrollee.You asked the Plan to provide coverage fora PET scan. You say that a PET scan 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 stating Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for positron emission tomography (PET scan ) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skullbase to mid-thigh.The Maximus Physician Reviewer determined that, based on current recommendations, it would be medically acceptable to perform a PET scan in men with high and very high-risk disease, as in this enrollee. If the results of conventional imaging, such as bone scan in this case, are negative or equivocal, next-generation imaging with F-18 fluciclovine PET/CT or Axumin PET/CT is medically appropriate in order to assess distant metastases.The Plan requested a reopen stating NCD 220.6.17 continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. The plan also notes that Axumin is only FDA-approved for PET imaging in men with suspected prostate cancer recurrence based on elevated PSA levels following prior treatment. The Plan states that this enrollee's prostate cancer was newly diagnosed, and the enrollee has not undergone any prior treatment for it. The Plan is correct in this case. The documentation does not support that the coverage criteria for PET scans, as established by NCD 220.6.17, have been met in this case. In addition, Axumin PET imaging is indicated for men with suspected prostate cancer recurrence based on elevated PSA levels following prior treatment. The enrollee in this case had not undergone prior treatment. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof a PET scan have not been met.Therefore, we decided that the Plan does not have to provide coverage fora positron emission tomography (PET) scan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora refraction visit received on January 22, 2020.You asked the Planto pay forthe visit. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered service.The Plan must follow Medicare rules. The rules say that Medicare does not cover eye refraction.The services you asked the Plan to pay for are considered refraction.Therefore, we decided that the Plandoes not haveto pay fora refraction visit received on January 22, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant tooth.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered 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
surgical placement of implant tooth.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection, triamcinolone acetonide (J3301) provided on August 14, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthe injection services. You say that you are disputing that the provider was out of network and have included a screenshot of the provider's in-network status.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe injection, triamcinolone acetonide (J3301) provided on August 14, 2019, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.
You asked the Plan to pre-approve a seat lift. You say that you have a hard time getting up from furniture due
to bad knees that need operations, inoperable back issues, and arthritis in your hands. The Plan denied your
request. The Plan says the information received did not show documentation of severe arthritis of the hip or
knee, or neuromuscular disease so the enrollee does not meet coverage criteria.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We asked our 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 seat lift. Our reviewer says that the seat lift does
not meet coverage criteria guidelines. The reviewer found the documentation does not indicate that you have
severe arthritis of the hip or knee, or a severe neuromuscular disease. The documentation also indicates that
you do not have the ability to ambulate after standing.
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of a seat lift have not been met. Therefore, we decided that the Plan does not have to preapprove
a seat lift.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapy services (97032, 97163, 97110) to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approveOON physical therapy services. You say that you are having surgery and will need physical therapy at the same hospital.The Plan denied your request. The Plan says the requested services are available in-network.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 provider at issue in this case is not anetwork provider with the Plan. 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 OON physical therapy services. Our reviewer says that the criteria for out-of-network services have not been met. Our physician reviewer found based on the medical records provided, there is no documentation that it is medically necessary for you to receive the requested services from the requested provider. There is no documentation in the medical records that an in-network provider cannot provide safe and effective therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of OON physical therapy services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON physical therapy services.Therefore, we decided that the Plan does not have to pre-approvethe physical therapy services (97032, 97163, 97110) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AUBAGIO 14mg tablets.
You asked the Plan to pre-approve AUBAGIO. You say that AUBAGIO is medically necessary. The Plan
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve AUBAGIO 14mg tablets.
Benefits for AUBAGIO 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee
on August 5, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health
of the patient are not a benefit.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the case file contains results of a urinalysis with reflex to UTI by RT-PCR testing. There are no clinical
records in the case file supporting that the testing at issue was medically reasonable and necessary for the
enrollee in this case.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for molecular genetic screening testing provided to the enrollee on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you believe a power scooter will aid in
mobility, particularly outside the home. The Plan denied your request. The Plan says you must be able to safely
operate that power vehicle, and it is not clear that it is possible due to vision impairment.
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.
The file shows that you cannot safely operate the PMD being requested. This means that Medicare rules for
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
power scooter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous vertebral augmentation or kyphoplasty (22514).
You asked the Plan to pre-approve the vertebral augmentation. You say that it is your medical opinion that vertebral augmentation is the next reasonable step to treat the enrollee's current medical situation. The Plan denied your request. The Plan says based on the medical records provided this request does not meet the requirements listed in the Local Coverage Determination (LCD).
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 vertebral augmentation. 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 documentation showing that this is an acute fracture less than 6 weeks old. Criteria for vertebral augmentation not met. 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 vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous vertebral augmentation or kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Medicare-covered eye examprovidedon March 2, 2020.You asked the Plan to waive the copayment for the Medicare-covered eye exam. You say that the provider is in-network and you should a zero copayment.The Plan denied your request. The Plan says when you receive vision care outpatient physician services provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries of the eye, including diagnosis or treatment for age-related macular degeneration or cataracts from an out-of-network provider there is a $60 copayment.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 $60 copayment for Medicare-covered eye exams when provided out-of-network.You have been asked to pay $60 copayment forthe Medicare-covered eye exam that was provided out-of-network. The Medicare-covered eye exam falls within the Vision Care, Medicare-covered eyeexam benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a Medicare-covered eye exam provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a first-time referral to a chiropractor for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the notes sent from the doctor do not show subluxation of the spine on an x-ray or an exam.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 referral Our reviewer says that the requested referral is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee has a subluxation that has resulted in a neuromuscular condition for which the requested chiropractic visit is medically indicated per Medicare guidelines. There is no documentation that the requested treatment will provide a significant and reasonable expectation of recovery or improvement of function.
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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a first-time referral to a chiropractor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria for coverage have not been met.
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.
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 Prolia. Our reviewer says that the
criteria for coverage of Prolia have not been met. Our physician reviewer found there is no documentation of
failure or inability to take calcitonin of other bisphosphonate drugs for osteoporosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe complete mandibular overdenture (D5865) and surgical placement of implant body (D6010).You asked the Plan to pre-approvethe complete mandibular overdenture and surgical placement of implant body. You say that these services are medically necessary.The Plan denied your request. The Plan says these services are not covered under your benefit package.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-approvethe complete mandibular overdenture (D5865) and surgical placement of implant body (D6010).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (3DA11, G0299, Q5001) provided.

You asked the Plan to pay for the home health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 codes 3DA11, G0299, & Q5001 is not supported in the medical record. Specifically, a required Request for Anticipated Payment (RAP) claim was not filed. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.Therefore, we decided that the Plan does not have to pay for home health services (3DA11, G0299, Q5001) provided.