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

We decided that the Plan does not have to pre-approve office services to be provided by an out of network (OON) provider at the in-network benefit level.
You asked the Plan to pre-approve office services. You say that you would like to continue care and therapy treatments for this enrollee. The Plan denied your request. The Plan says the denial of authorization for in-network coverage for these services, because this provider is out-of-network with the Plan and the enrollee can be treated by in-network providers including in-network tertiary level of care providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees may choose to receive care from in-network or out-of-network providers who are eligible to provider service under Original Medicare. The share of costs for covered out-of-network services may be higher. 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 at the in-network benefit level. The enrollee may choose to receive care from this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve office services to be provided by an out of network (OON) provider at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair (E1161) and accessories (K0195, E1225, E1028, E0955, E0973, E2231, E0961, E0971, K0040, E2609, E2617).

You asked the Plan to pre-approve a wheelchair and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered while the enrollee is in a nursing facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that a wheelchair and accessories are being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a wheelchair (E1161) and accessories (K0195, E1225, E1028, E0955, E0973, E2231, E0961, E0971, K0040, E2609, E2617).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services provided to the enrollee on April 13, 2020 and billed under code 0450.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan says that this claim was submitted under code 0450 and not the required revenue code of 0510, per the rules for payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be paid as billed due to the omission of the appropriate codes for this service under the Medicare rules for Indian Health services. Therefore, we decided that the Plan does not have to pay for emergency department services provided to the enrollee on April 13, 2020 and billed under code 0450.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you do not want to travel to the provider that is in-network. The Plan denied your request. The Plan says the provider you requested is not in-network. You must receive your care from a network provider.
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 accessible 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 (99205) 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 pre-approve shower/bath chair (E0240) bathtub rail (E0241) toilet rail (E0243x4) transfer bench tub/toilet (E0247).
You asked the Plan to pre-approve the shower chair, rails and transfer bench. You say that you are in desperate need of these items because every time you try to step over the tub, you lose your balance, get dizzy and falls on the floor. You have already broken the toilet from falling trying to get into the shower. The Plan denied your request. The Plan says these items are convenience items and are not covered by Medicare.
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 Plan does not have to pre-approve shower/bath chair (E0240) bathtub rail (E0241) toilet rail (E0243x4) transfer bench tub/toilet (E0247).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (PWC).
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 covered.
The Plan must follow Medicare rules. Medicare rules say that a Group 4 PWC is denied as not medically necessary. We looked at the file and Medicare rules. The services at issue are a Group 4 PWC. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Group 4 power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard for spinal stenosis decompression. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 do not require the intensity of services provided at an IRF. Specifically, you are 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four physical therapy (PT) visits.

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 four visits are approved and four further are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has a history of right shoulder pain and has been
receiving PT after a right shoulder hemiarthroplasty. He has had 33 PT sessions. Four further visits are not
generally accepted as specific and effective therapy for the enrollee's condition. He appears to have some
aggravation of her condition due to the physical therapy. Further therapy at this point does not appear to be
likely to achieve any significant improvement in the enrollee's symptoms or functional status. There is no
documentation that the unique skills of a professional therapist are required to safely and effectively provide
treatment, that the services can be safely and effectively performed only by a therapist or under the supervision
of a therapist. The services are not part of a maintenance program and are 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve four physical therapy (PT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex interspinous spacer is considered experimental and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous process decompression device (22870).
You asked the Plan to pre-approve the Vertiflex decompression device. You say that you are writing to request an appeal review in response to a preauthorization denial for the posterior interspinous decompression procedure to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says this procedure is not supported by current medical literature. There have not been enough quality studies to support efficacy and safety.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex decompression device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex interspinous process decompression device (22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a beside commode.
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 covered.
The Plan must follow Medicare rules. The rules say that a commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities. We looked at the file and Medicare rules. The records show that you are not confined to a single room, one level of the home, or confined to a home without toilet facilities. 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 a beside commode.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance 10 mg tablet.

You asked the Plan to pre-approve Jardiance. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the member's medical 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 Jardiance 10 mg tablet.

Benefits for Jardiance 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).
You asked the Plan to pre-approve sacroiliac joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 sacroiliac joint injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee and billed under claim A.

You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states claim A denied because payment was previously made for this service. The Plan records show payment was made to a provider in the same group for the same date of service. The Plan states the NPI website shows both providers share a primary taxonomy of Radiology and Diagnostic Radiology. The Plan included both claims for review which each were submitted with the same billing provider NPI and Tax ID, and both providers belong to the same physician group.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee and bulled under claim A for code 71045.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that this is necessary due to the enrollee's stroke. The Plan denied your request. The Plan says the requested services are custodial.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the requested home health services are not medically necessary at this time. Our physician reviewer found the records do not show that skilled nursing or therapy services are required to effectively provide treatment to improve the enrollee's level of function, maintain the enrollee's level of function, or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
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. You say that LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current
level of care.

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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current 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 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 the IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different 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 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. The enrollee's needs can be met at an alternate 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient occupational therapy (OT)
services.
You asked the Plan to pre-approve the additional OT services. You say that the services are medically
necessary. The Plan denied your request. The Plan says the additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional OT services. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the enrollee has had extensive prior therapy and the
records do not demonstrate that the unique skills of a professional therapist are required to safely and
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist.
The patient and caregivers have been instructed on a home exercise plan and the plan authorized 2 sessions for
discharge instructions.
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 additional OT services have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional outpatient occupational therapy (OT) services.