Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism with chair.
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 medically necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 records do not show that you have severe arthritis of the hip or knee or neuromuscular disease. A seat lift mechanism is not included in the physician progress notes as a course of treatment. The records do not support that the seat lift will likely effect improvement in your condition or arrest or slow deterioration, or that you are completely incapable of standing from a chair in the home and ambulation. The seat lift mechanism is 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. The chair is not covered because it does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism with chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skin substitute (Q4186 Epifix).
You asked the Plan to pre-approve a skin substitute. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section of this letter must be met for skin substitutes to be considered 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 a skin substitute. Our reviewer says that the service is not medically necessary. Our physician reviewer found you have type two diabetes mellitus with a foot ulcer. You have received standard wound therapy and the wound measurements have reduced in size over the past consecutive thirty days suggestive of progress in healing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a skin substitute have not been met. Specifically, your wound is responding to standard wound therapy. Therefore, we decided that the Plan does not have to pre-approve a skin substitute (Q4186 Epifix).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that you were admitted to the current acute care hospital with renal calculi requiring cystoscopy with ureteroscopy and stent placement. You appear to be improving. You require only short-term additional acute care services, which can be safely administered at the current facility for now. You do not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device.
You asked the Plan to pre-approve Vertiflex device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic lumbar pain and spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated severe spinal stenosis at L3-L4 and moderate to severe spinal stenosis at L4-L5, the level requested for treatment. The elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee.
The Plan denied your request. The Plan says Medicare coverage criteria for this drug are not met. 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 Keytruda. The
Maximus Physician Reviewer determined that the requested use of Keytruda is FDA-approved for the
enrollee's diagnosis. National Comprehensive Cancer Network (NCCN) guidelines state that Keytruda can be
used until toxicity or progression or 24 months. Mayne experts will continue until toxicity or progression given
the high risk of recurrence. The documentation supports that the requested use of Keytruda is safe and effective
and otherwise reasonable and necessary for the enrollee. The Plan argues that the package insert clearly states "
..or up to 24 months in patients without disease progression." The Plan states that the "clinical value and
effectiveness of Keytruda in the setting of treatment beyond 24 months duration have not been demonstrated in
the peer-reviewed literature."
The medical records show the enrollee is a 79-year-old man with a diagnosis of metastatic bladder cancer. The
enrollee has been in remission on Keytruda for 3 years. Continued therapy was requested. The enrollee's
oncologist writes that small cell cancers of any origin are difficult to treat, and the enrollee does not have any
good alternative treatment options if/when his disease relapses after stopping Keytruda.
Our Medical Director has concluded that the Plan is correct in this case. The FDA-approved label for Keytruda
states that the duration/timing of treatment for patients with locally advanced or metastatic urothelial carcinoma
is until disease progression, unacceptable toxicity, or up to 24 months. We looked at this physician's review, the
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda
have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation of genicular nerve branches (64624).
You asked the Plan to pre-approve a radiofrequency ablation of genicular nerve branches. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the procedure at issue is experimental/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 a radiofrequency ablation of genicular nerve branches. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational and is the subject of ongoing clinical trials.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a radiofrequency ablation of genicular nerve branches have not been met.
Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation of genicular nerve
branches (64624).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the platelet rich plasma injection (0232T).
You asked the Plan to pre-approve the platelet rich plasma injection. You say that you would like reconsideration because your pain in constant and you have tried other means of therapy without relief. The Plan denied your request. The Plan says the requested injection is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient high-quality evidence to justify the use of PRP for the treatment of any condition except for within the confines of a well-designed clinical trial. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the platelet rich plasma injection have not been met. Specifically, the record does not show that this service is being requested as a part of a clinical trial.
Outside of the clinical trial setting, this service is not a covered Medicare benefit. Therefore, we decided that
the Plan does not have to pre-approve the platelet rich plasma injection (0232T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve limited orthodontic treatment of the adult dentition (D8040).
You asked the Plan to pre-approve limited orthodontic treatment of the adult dentition. You say that the service at issue is necessary. The Plan denied your request. The Plan says the service at issue 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 limited orthodontic treatment of the adult dentition (D8040).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology specialist consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the neurology specialist consultation. You say that your condition is urgent, and you need help. 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 neurology specialist consultation 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 pre-approve gingival irrigation (D4921) and alveoloplasty (D7311).
You asked the Plan to pre-approve gingival irrigation (D4921) and alveoloplasty (D7311). The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921) and alveoloplasty (D7311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT code
78608), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your
request. The Plan says the enrollee's doctor did not tell the Plan that the enrollee has had special tests to check
how well the enrollee is able to reason, solve problems, concentrate, and remember. The Plan states based on
the information they have this test is not 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 PET scan. Our physician reviewer
found the record indicates that the enrollee has cognitive impairment with behavioral disturbance and
unspecified dementia. Imaging demonstrated mild to moderate global atrophy as well as basal ganglia lacunar
infarct. No cognitive testing has been performed. The record indicates that the enrollee is unable to be left
alone and has had a decline of the past year. Vascular etiologies as well as Korsakoff syndrome are under
consideration. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.
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), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you need this bed due to your medical issues. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found you had gastrointestinal bleeding and has undergone recent surgery for colon cancer. The documentation shows that you have generalized weakness and inability to ambulate but there is no documentation that your condition requires position of the body in ways not feasible in an ordinary bed or the need for immediate changes in body position. Therefore, you do not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospitalization
You asked the Plan to pay for acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital for an elective procedure. The records did not show this patient being at high risk for complication or need for hospitalization associated with this procedure.
It was not expected that the patient would require hospital services that would likely cross two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, medically necessary services could be obtained in an observational level of care. This means inpatient hospitalization is not reasonable or necessary. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospitalization
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you will need the requested items for the rest of your life, and they should continue to be covered through your insurance. The Plan denied your request. The Plan says rules for compression stockings have not been met.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an LTACH and requires services that are only available at an LTACH. The Plan denied your request. The Plan says the enrollee's condition at this time is complex and not stable for transfer. Necessary services are being provided at the current acute care hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided demonstrating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available and covered at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
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 cannot get the same level of care at a skilled nursing facility, and you are too weak to go home now. The Plan denied your request. The Plan says the criteria for an IRF have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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.
Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 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-approve acute inpatient rehabilitation facility (IRF) admission and services.