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

We decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on September 3, 2020.

You asked the Plan to pay for the testing services. You say that the results of the testing allow physicians to effectively make treatment decisions. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. In this case, there are insufficient medical records to show the results of the testing would be used in the management of a specific medical problem for the enrollee. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on September 3, 2020.
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 the requested IRF services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet requirements for approval of IRF services.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided January 12, 2021.

You asked the Plan to pay for foot orthotics. You say that the orthotics were medically necessary and should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Padcev.
You asked the Plan to pre-approve Padcev. You say that you would like reconsideration because the member would like to continue the use of this drug off-trial. The Plan denied your request. The Plan says the requested drug is not indicated for the member's condition.
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 Padcev. Our reviewer says that the elements of the coverage criteria are not satisfied and the requested service cannot be recommended. Our physician reviewer found the Medicare compendia do not support the use of the requested drug for the noted indication and the drug is under investigation for the noted indication. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Padcev have not been met. Therefore, we decided that the Plan does not have to pre-approve Padcev.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on October 23, 2020.

You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the $1000 allowance had been exhausted prior to this date of service. Maximus overturned the Plans denial, stating the contract provided indicated you had a $2000 allowance. The Plan requested a reopen and provided the correct contract for review as the incorrect contract had been submitted with the case file.

Based on resubmitted contract information, 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, the dental records show you had services covered on February 12, 2020 for $345, February 17, 2020 for $237, and February 25, 2020 for $418 which totals $1000.

Therefore, the $1000 allowance was exhausted prior to the services reviewed in this appeal. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on October 23, 2020.
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 exceeds the criteria for coverage of LTACH care. You say that the clinical documentation provided supports this need. You say that LTACH care is the most appropriate and the most optimal opportunity for a successful outcome. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current hospital setting.

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, who has chronic respiratory failure due to neuromuscular disease, was admitted with worsening hypoxic respiratory failure due to pneumonia. The enrollee continues to be febrile, tachycardia, tachypneic, and exhibit a leukocytosis. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.

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 need IRF care to regain strength. The Plan
denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for surgical repair of a hip fracture
after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is
no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. In conclusion, 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (88120) provided on October 13,
2020.
You asked the Plan to pay for cytopathology services. You say that this was billed with an appropriate
diagnosis. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that while diagnosis R31.29, other microscopic
hematuria, can support medical necessity for testing billed with 88120, it is to be used only when repeat testing
is believed to be medically reasonable and necessary, and must be listed as secondary with the primary
neoplastic diagnosis.
We looked at the file and Medicare rules. The service at issue was billed with R31.29 as the primary and only
diagnosis. Medicare rules specify that this should be listed as a secondary diagnosis. Based on this information,
we decided that Medicare rules for coverage of cytopathology services have not been met. Therefore, we
decided that the Plan does not have to pay for cytopathology services (88120) provided on October 13, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not meet complexity of nursing, medical management, and rehabilitation requiring an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You have a past medical history of degenerative disc
disease, lumbar radiculopathy, diabetes, hypertension, morbid obesity, osteoarthritis and Parkinson's disease
and are living at home with impaired mobility, leg pain and low back pain. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. Medically
necessary services can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
September 28, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. It would also not have an indication for use in an older patient with established known cardiovascular disease. Cardiac gene variant testing is therefore not currently recommended for general risk stratification and would not be considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 22, 2020.

You asked the Plan to pay for therapeutic exercises. You say that this should be covered as an in-network service. The Plan denied your request. The Plan says this was not billed correctly.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, this service was provided in a home health setting. There is a more appropriate code for this service.

Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 22, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xofigo, 1,000 KBQ/ML vial.

You asked the Plan to pre-approve Xofigo. You say that the enrollee has LN less than 3 centimeters. You say that per the trial this was not considered visceral metastase. You also say that this is medically necessary. The Plan denied your request. The Plan says that that Xofigo is not approved for the requested use by the Food and Drug Administration (FDA).

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 Xofigo. Our reviewer says that Xofigo is medically necessary. Our physician reviewer found that Xofigo is not FDA-approved for the enrollee's diagnosis. However, the reviewer found that per Micromedex drug compendium, Xofigo is indicated for treatment of hormone-refractory prostate cancer with bone pain when there are no visceral metastases. Therefore, the reviewer found that the requested use of Xofigo is medically reasonable and 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 Xofigo have been met. Therefore, we decided that the Plan has to pre-approve Xofigo, 1,000 KBQ/ML vial.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76140) provided December 2, 2020.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed is not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 76140 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this CPT code has a status of "I" which means it is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76140) provided December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673) provided on January 27, 2021.

You asked the Plan to pay for a pneumatic compression device and related accessories. You say that the requested items are necessary for use by the enrollee in the home. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0675 is used only for peripheral artery disease and that, if the base PCD is not covered, related accessories are not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the case record reflects that the requested item is prescribed for prevention of deep venous thrombosis (DVT) or pulmonary embolisms (PE). As prescribed, the requested item is not a covered benefit of Medicare or the Plan. The related accessories coded E0673 are not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related accessories (E0673) provided on January 27, 2021.
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 the records provided support the need for IRF care.
The Plan denied your request. The Plan says the clinical information provided does not show that there are
complex medical needs that require intensive rehabilitation.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for thoracolumbar spine surgery after a motor vehicle collision. He was treated for
rhabdomyolysis and anemia. The enrollee's medical conditions are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require
physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that this enrollee 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.