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

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that this request is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered 
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 prostate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible 
short-term safety and efficacy. The most recent American Urological Association guidelines do not recommend 
this procedure outside of a clinical trial 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 prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drainage of a gum lesion (41800) provided on January 29, 2021.

You asked the Plan to pay for the dental service. You say that the enrollee went to the Emergency Room (ER) on this date of service. You also say that the enrollee was seen by an ER physician for a medically necessary procedure. The Plan denied your request. The Plan says the service you received is dental in nature. The Plan also says that routine dental services are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule.

Though the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the drainage of a gum lesion (41800) provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the recent records do not indicate any benefit is being received from skilled services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled nursing or skilled therapy needs. You are ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy.
You asked the Plan to pre-approve endodontic therapy. You say that you are requesting authorization for a root canal. You say that you were told you would be covered for this service when you signed up for the Plan. The Plan denied your request. The Plan says the service 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 endodontic therapy.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an oxygen concentrator and portable oxygen.
You asked the Plan to pre-approve an oxygen concentrator and portable oxygen. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested items are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The case file that was sent to Maximus was largely incomplete. Required documentation such as the initial authorization request, Plan's initial denial, Reconsideration request, Plan's Reconsideration Denial, and any medical records used in making the Plan's decision were not provided with the case file. Maximus requested this documentation from the Plan on three occasions without response. This means the Plan did not substantiate their decision. Therefore, we decided that the Plan has to pre-approve an oxygen concentrator and portable oxygen.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the enrollee does not require daily skilled services to address an acute illness or injury.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that SNF services are medically reasonable and necessary for the enrollee in this case. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her baseline and not ambulating household distances. The enrollee has not yet been shown to have reached a new plateau in function. A trial of skilled therapy is reasonable to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF 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 SNF services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code (s): 87798, 87486, 87541, 87581, 87640, 87496 and 87498) provided to the enrollee on April 17, 2020.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. CPT code 87798 (6 Units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.

CPT code(s): 87486, 87541, 87581, 87640 87496, and 87498 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Assisted Living Facility (POS code 13), the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory testing (CPT code (s): 87798, 87486, 87541, 87581, 87640, 87496 and 87498) provided to the enrollee on April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for oxygen equipment received on January 22, 2021.
You asked the Plan to pay for the services. You say that your doctor prescribed this item to you. The Plan denied your request. The Plan says that there must be approval from the plan to be able to get durable medical equipment.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the equipment by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan, as a contract provider of the plan is considered an agent of the plan. Therefore, we decided that the Plan has to pay for oxygen equipment received on January 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic intermittent leukopenia since 2017. There is no cancer, fever, or infections. Udenyca is recommended for recurrent infections and not recommended for prevention. Use should not be based on the severity of the neutropenia, but rather based on the presence of recurrent infections. This enrollee is not reported as having recurrent infection just upcoming hip replacement. Udenyca is not considered safe and effective, as it can be associated with severe side effects, and is 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-approve Udenyca.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you were told that you needed to go back after 6 months. You say that you would like this visit approved. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270 x 3) provided in an outpatient setting on March 23, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were given 3 drugs that were used in for the preparation, during, an after your surgery. You say that you were instructed to continue these medications until you returned for a follow-up appointment. You also say that you feel this was out of your control and should not be responsible for the charge. The Plan denied your request. The Plan says procedure code A9270 is a non-covered item or service.
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 pay for the self-administered drugs (A9270 x 3) provided in an outpatient setting on March 23, 2021.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 26, 2021.

You asked the Plan to pay for the orthoses. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address Coronavirus concerns. The Plan denied your request. The Plan says there is evidence of misrepresented services.

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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic knee pain. The record does not indicate that the enrollee has had a recent injury or surgery. The record does not indicate hat the enrollee has knee instability documented by examination of the beneficiary and objective description of joint laxity. The elements of the coverage criteria are not satisfied. 

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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like to use this provider because they come recommended by a family member. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.
Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis and ultraviolet light therapy system provided on January 21, 2021.
You asked the Plan to pay for the wrist hand orthosis (L3916) and ultraviolet light therapy system (E0691). You say that the orthoses are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition of medical necessity and there was no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The delivery slip did not have the tracking number on it and the medical records do not support medical necessity for the orthosis or light therapy system. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis and ultraviolet light therapy system provided on January 21, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospital admission and services.
You asked the Plan to pre-approve inpatient psychiatric hospital care. You say that mental health services on an inpatient basis are medically necessary for this enrollee. The Plan denied your request. The Plan says that the requested care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital care. Our reviewer says that health plan's denial of inpatient psychiatric services appears inappropriate. Our physician reviewer found that the enrollee was admitted to an acute inpatient psychiatric hospital on August 3, 2021, with Schizoaffective Disorder, Bipolar Type and Cocaine Dependence with Withdrawal. Based on a review of the provided records, it was expected this enrollee would improve in a reasonable period of time as they did have dangerousness to self but not others. There were auditory hallucinations and delusions but no visual hallucinations. They were showing aggressive behavioral issues. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than at a lower level, as the enrollee did have dangerousness to self not others and perceptual disturbances. It also appears that active treatment was taking place and the services were reasonably expected to improve the enrollee's condition for the purpose of diagnosis. Our reviewer was unable to find an individualized treatment plan; however, the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, the admission of this patient does meet the criteria for acute inpatient mental health treatment as this patient was shown to be a danger to himself not others with agitation or aggression and with perceptual disturbance including auditory no visual hallucinations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital care have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric hospital admission and services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole.
You asked the Plan to pre-approve Omeprazole. You say that the enrollee has gastric ulcers. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Omeprazole.
Benefits for Omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.