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

We decided that the Plan does not have to pre-approve the transcatheter placement of artery stent (37236).
You asked the Plan to pre-approve the transcatheter placement of artery stent. You say that this service is medically necessary. The Plan denied your request. The Plan says the services requested in this case are not medially reasonable and 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 transcatheter placement of artery stent. 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 that the patient is having lifestyle limiting symptoms and there is no documentation suggesting limb threat. The results of the Computed tomography angiography (CTA) provided specifically notes that there is no significant iliac stenosis. In addition, there are no noninvasive vascular studies suggesting significant abnormal perfusions lower extremities provided. Physical examination of the extremities is documented as normal. The documentation lacks a cohesive assessment and plan articulating the indications for and rationale for arterial intervention including stenting. 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 transcatheter placement of artery stent have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcatheter placement of artery stent (37236).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Novolog Injection Flexpen. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the is not covered for the enrollee. 
 
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 Novolog Injection Flexpen.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FLAREX 0.1% ophthalmic suspension for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a commercial pharmacy 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 FLAREX 0.1% ophthalmic 
suspension for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. You say that you are not at your prior level of function.The Plan denied your request. The Plan says there is no need for daily skilled therapy or nursing needs.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our physician reviewer found that you do nothave complex woundcare or other skilled nursingneeds that requires a SNF stay. Yourfunctional level does not require skilled therapy services of a qualified therapist provide medically necessary treatment only in a SNF. Skilled services are not needed on a daily basis,or as practical matter in a skilled nursing facility setting.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services (V2762, V2781). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, 
we decided that the Plan does not have to pre-approve vision services (V2762, V2781).
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 cannot be adequately cared
for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the
enrollee has not completed his full course of care in the 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 physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-
19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH.
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 long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 the enrollee was admitted to the hospital for acute on chronic respiratory failure. The 
enrollee's hospital stay has been complicated by respiratory failure requiring a period of intubation, acute on 
chronic protein calorie malnutrition, acute on chronic anemia requiring transfusion, and metabolic 
encephalopathy. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. 
 
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: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan does not have to provide coverage for dental services coded as D3310, root canal, for the enrollee.You asked the Plan to pre-approveseveral dental services. You say that this root canal should be covered by the Plan.The Plan denied your request. The Plan says the enrollee'sdental benefit does not include root canals. Maximus partially overturned the originalappeal from the Plan and stated the root canal should be covered. The Plan requested a reopen and stated Maximus did not apply the correct dental coverage.The Plan is correct in this case. Medicare does not cover dental services. 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 root canal is clearly listed as a non-covered service. Therefore, we decided that the Plan does not have to provide coverage for dental services coded as D3310, root canal, for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildups, including any pins when required (D2950), gingivectomy or gingivoplasty (D4212), pontics (D6245), and retainer crowns (D6740).You asked the Plan to pre-approvethe core buildups, gingivectomy or gingivoplasty, pontics, and retainer crowns. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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-approvecore buildups, including any pins when required (D2950), gingivectomy or gingivoplasty (D4212), pontics (D6245), and retainer crowns (D6740)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical therapy and hospital care. 
The Plan denied your request. The Plan says the enrollee's rehab needs does not require an intensive team 
approach. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee is at a minimal assist level for sitting and standing up, and at minimal assist for walking using 
a rolling walker. The enrollee does not require the intensity of services provided at an IRF.  Specifically, the 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services after February 3, 2021.You asked the Plan to pre-approve the continuation of SNF services. You say that you do not feel ready to be released from SNF care at this time. You say that your right leg is still very weak and you need more time with physical therapy. The Plan denied your request. The Plan says continuation of SNF services 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 above 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 therequest to pre-approve the continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral and inhaled medications.You had stable vital signs. Your lungs were clear. Regarding rehabilitation services, you received physical therapy and occupational therapy in the SNF.By the dates in question, you were at a stand by assist/supervision to contact guard assist level with functional mobility including gait to 150 feet with a front wheeled walker.You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs.There are no identifiable skilled therapy service needs.You do not require skilled nursing or therapy services on a daily basis.As a practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after February 3, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous device for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the clinical value and effectiveness of the Vertiflex Superion Interspinous device in the setting of lumbar spinal stenosis has not been demonstrated in the peer-reviewed literature.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinterspinous ligament spacers (22869, 22870).You asked the Plan to pre-approveinterspinous ligament spacers. You say that the requesteditems/services are medically necessary.The Plan denied your request. The Plan says rules for pre-approval have not been met.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 interspinous ligament spacers. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacersareexperimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous ligament spacershave not been met.Therefore, we decided that the Plan does not have to pre-approveinterspinous ligament spacers (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the contact lenses provided on June 4, 
2020. 
 
You asked the Plan to make additional payment for the contact lenses. You say that you feel that your routine 
vision claim was incorrectly denied. The Plan denied your request. The Plan says the Plan correctly applied the 
$200 credit to your contact 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 provides a $200 allowance toward routine eyewear.  

We looked at the file and the Plan's rules. We found that the cost of the purchased contact lenses was $286. 
You are being asked to pay only $86 for the lenses. This means the credit was correctly applied. Based on this 
information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, 
we decided that the Plan does not have to make additional payment for the contact lenses provided on June 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a Group 2, very heavy duty power mobility device. 
 
You asked the Plan to provide a Group 2, very heavy duty power mobility device (K0808). You say that the 
enrollee needs a very heavy duty PMD. The Plan denied your request. The Plan says the enrollee does not meet 
the weight requirements for a very heavy duty PMD. 
 
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 the enrollee is below the weight range for a heavy duty and very heavy duty PMD. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to provide a Group 2, very heavy duty power mobility device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided July 10, 2020 to August 8, 2020.You asked the Plan to pay forthe SNF services. You say that the services were medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows that the enrollee did not require skilled nursing or therapy services on a daily 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided July 10, 2020 to August 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Hyaluronan injection.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee has not failed conservative measures.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 the requested services. Our physician reviewer found that an imaging report reveals tricompartmental degenerative changes with collapse of the lateral compartment on lateral and sunrise left knee x-rays. The enrolleereports having her left knee drained again. On exam there is 0 to 90 degrees of flexion, intact stability, no joint effusion,and stable neurovascular status. Shehas diffuse left knee tenderness. The documentation does indicate left knee arthritis on a left knee x-ray. The documentation does not reveal that shehas failed at least 3 months of conservative therapy.  The requested Hyaluronan injection  is 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Hyaluronan injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVallium (Diazepam) tablets.You asked the Plan to pre-approveVallium. You say that this is the only medication that controls the enrollee's symptoms.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.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-approveVallium (Diazepam) tablets.Benefits for Valliummay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea whirlpool hot tub.You asked the Planto pre-approvethe hot tub. You say that this is needed for a medical purpose, for pain control.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea whirlpool hot tub.