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

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that it is extremely important to have the surgery because the polyps might be cancerous. You say you would prefer to use the recommended doctor because you are anxious about the procedure. The Plan denied your request. The Plan says the provider is out-of-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 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 the office visit to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow.

You asked the Plan to pre-approve Fluid Flow. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the requested service does not meet Medicare criteria.

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 Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is not FDA approved and is considered experimental.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FlowerAmnioFlo amniotic liquid allograft injection (Q4177).
You asked the Plan to pre-approve the FlowerAmnioFlo amniotic liquid allograft injection (Q4177). You say that the requested FlowerAmnioFlo injection is medically necessary. The Plan denied your request. The Plan says the requested FlowerAmnioFlo injection is 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 the FlowerAmnioFlo amniotic liquid allograft injection (Q4177). Our reviewer says that the requested FlowerAmnioFlo injection is not medically necessary. Our physician reviewer found the enrollee was being treated for right knee osteoarthritis. He presented with right knee pain rated at 8/10 and is unable to do normal activities of daily living. Pain is exacerbated by going up/downstairs, bending down, squatting, carrying heavy objects, and prolonged walking. Exam reveals right knee motion of flexion at 80. There is crepitus. There is anterior/posterior drawer varus on the right. He has KL grade 3 right knee osteoarthritis.
Current evidence based medical peer reviewed literature indicate that stem cell type therapy remains investigational for the treatment of knee osteoarthritis and knee cartilage regeneration. 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 FlowerAmnioFlo injection 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 FlowerAmnioFlo amniotic liquid allograft injection (Q4177) have not been met. Therefore, we decided that the Plan does not have to pre-approve the FlowerAmnioFlo amniotic liquid allograft injection (Q4177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 2D oral/facial photographic image (D0350), diagnostic casts (D0470), and comprehensive orthodontic treatment of the adult dentition (D8090).
You asked the Plan to pre-approve the 2D oral/facial photographic image, diagnostic casts, and comprehensive orthodontic treatment. You say that you feel 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-approve a 2D oral/facial photographic image (D0350), diagnostic casts (D0470), and comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core buildup, including any pins when required (D2950), and endodontic therapy (D3320).
You asked the Plan to pre-approve the crown, core buildup, and endodontic therapy. You say that you are on a fixed income, and need these services to be approved for coverage. The Plan denied your request. The Plan says these 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 crown (D2740), core buildup, including any pins when required (D2950), and endodontic therapy (D3320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Imfinzi (J9173).
You asked the Plan to pre-approve Imfinzi. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an unsupported use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Imfinzi. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the requested use of Imfinzi is not FDA-approved for the enrollee's diagnosis of non-small cell lung cancer, status post chemotherapy and radiation with progression of disease. Furthermore, this use is not supported by any of the major drug compendia nor by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Imfinzi (J9173).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor (CGM). You say that your doctor ordered the CGM. The Plan denied your request. The Plan says criteria is not met for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on August 25, 2020.

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 procedure code 99284 is not supported.

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 99284 is Level 4 emergency department visit for evaluation and management of patient with problem of high severity, including detailed history and physical examination, and medical decision-making of moderate complexity. 

We find that CPT code 99284 is not supported in the medical record. Specifically, the documentation does not support Level 4 ER services. 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 pay for the emergency room (ER) services rendered on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750), prefabricated post and core in addition to crown (D2954), endodontic therapy (D3310), maxillary partial denture (D5213), and mandibular partial denture (D5214).
You asked the Plan to pre-approve the crown, prefabricated post and core, endodontic therapy, maxillary partial denture, and mandibular partial denture. You say that you need 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 crown (D2750), prefabricated post and core in addition to crown (D2954), endodontic therapy (D3310), maxillary partial denture (D5213), and mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services provided as part of a phase III clinical trial.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not payable by Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the requested services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve services provided as part of a phase III clinical trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are unhappy with this denial. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you only use insulin twice daily, check your blood sugar three times daily, and do not require frequent adjustments to your insulin regimen based on your blood glucose results.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor, pocket doppler monitor, and ultrasound gel.
You asked the Plan to pre-approve home blood pressure monitor, pocket doppler monitor, and ultrasound gel. You say that you need these items to monitor your condition daily. The Plan denied your request. The Plan says these items are not primarily medical in nature and are considered non-covered convenience items.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. The pocket doppler monitor and ultrasound gel at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor, pocket doppler monitor, and ultrasound gel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 17, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on August 14, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 fractions of Stereotactic Body Radiation Therapy for the enrollee.

You asked the Plan to pre-approve Stereotactic Body Radiation Therapy. You say that the requested treatment is medically necessary.

The Plan denied your request. The Plan says Medicare only covers 5 fractions of therapy in this case. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Stereotactic body radiation therapy (SBRT). The Maximus Physician Reviewer determined that, although the primary treatment for most patients with metastatic cancer is systemic therapy, stereotactic body radiation therapy (SBRT) is being evaluated in those with few metastatic sites (oligometastatic disease). The Plan requested a reopen and stated that 8 fractions of SBRT were requested, however the maximum number of treatments allowed by Medicare for SBRT is 5 fractions.

Our Medical Director has concluded that the Plan is correct in this case. 8 fractions of SBRT were requested, and the Medicare LCD limits the number of SBRT fractions to 5. Medicare coverage criteria for 8 are not met as this amount is not allowed by Medicare. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Stereotactic Body Radiation Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 fractions of Stereotactic Body Radiation Therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the DTap vaccination provided on January 7, 2021.
You asked the Plan to pay for Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use (90700). You say that the vaccines should be covered because a surgery wiped out all your vaccines. The Plan denied your request. The Plan says this code is not correct for an enrollee of your age.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use (90700). The Plan follows the same rules.
Records show that you are not an individual younger than 7 years. This vaccination has been submitted with an incorrect code. Therefore, we decided that the Plan does not have to pay for the DTap vaccination provided on January 7, 2021.