Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lower extremity joint.

You asked the Plan to pre-approve the MRI. You say that this is needed to plan the surgery. The Plan denied your request. The Plan says that the records do not show a recent trial of doctor-prescribed treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the medical documentation establishes that you are having significant ankle pain, right side greater than left. You have attempted prior treatments, including CAM boot immobilization, as well as Amnion injections the joint. A decision has been made to move forward with surgical intervention, including possible ankle joint effusion and or ankle joint replacement. You have undergone x-ray evaluation of the right ankle, which notes ankle osteoarthritis. The physician requests an MRI of the lower extremity prior to surgical intervention, to allow for surgical planning and to evaluate the soft tissue structures surrounding the joint. This is a necessary step prior to surgery in order to evaluate the integrity of the surrounding soft tissue, tendons, and ligaments and to make sure that any pathologic soft tissue is addressed during the surgery.

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lower extremity joint.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography.
You asked the Plan to pre-approve a computed tomography (CT), abdomen and pelvis; without contrast material (74176). You say that the enrollee needs a CT because of abdominal pain. The Plan denied your request. The Plan says the routine use of CT abdomen and pelvis for non-specific abdominal pain does not meet reasonable and necessary criteria for medical necessity.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT), abdomen and pelvis; without contrast material (74176). Our reviewer says that a CT is not medically necessary. Our physician reviewer found the routine use of CT scans to evaluate non-specific abdominal pain in a young individual is not necessary. In general, the first step in the evaluation of abdominal pain should include basic laboratory assessment, unstable angina, lipase amylase and pregnancy testing. Until this testing is conducted, the use of CT scanning is not warranted. The review indicates that the requested CT scan is not 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 a computed tomography (CT), abdomen and pelvis; without contrast material (74176) have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone and/or joint imaging, 3 phase study for the enrollee.

You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says there was only a limited physical exam.

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 imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provided medical records indicate that the back pain is not at the sight of the compression fracture. There is also a diagnosis of sacroiliitis. The bone scan is ordered to assess for a pelvic insufficiency fracture. Other studies are more effective to establish the considered diagnoses. 

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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve bone and/or joint imaging, 3 phase study for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eyelid procedure.
You asked the Plan to pre-approve an eyelid procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that these surgeries (either individually or in the minimum combination required to achieve a satisfactory surgical outcome) are functional when specific criteria are met. 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 an eyelid procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the provided medical record does not indicate the field restriction or margin reflex distance. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an eyelid procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an eyelid procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and a prefabricated post and core (D2954) for tooth #13.
You asked the Plan to pre-approve the crown and post. You say that your current crown needs replaced, and you cannot afford a new one. The Plan denied your request. The Plan says you had a crown with a post and core provided for this tooth in 2019. These services are only eligible for coverage once per 60 months per tooth.
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 covered under this benefit in the requested frequency. Documentation was provided to show that you had these services for the requested tooth in 2019, which is less than 60 months before this request. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) and a prefabricated post and core (D2954) for tooth #13.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transportation ancillary, additional Logisticare mileage (A0170).

You asked the Plan to pre-approve the additional mileage. You say that you been going to this provider for 5 years and would like to continue going but you need transportation. The Plan denied your request. The Plan says this request exceeds the benefit limit of 50 miles.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips. Each one-way trip must not exceed 50 miles. 

We looked at your request, the records in the case file, and the rules. You have requested an additional 4.3 miles for each trip to total 54.3 miles per trip. Based on this information, we decided that this request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve transportation ancillary, additional Logisticare mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you have falls in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 150 Skin Barrier Wipe or Swab (A5120).
You asked the Plan to pre-approve Skin Barrier Wipes. You say that the claim for the supplies should be paid. The Plan denied your request. The Plan says the Plan has previously paid for 150 skin barrier wipes under another authorization number, so it will not approve another 150 as it is beyond the allotted amount set out in the LCD.
The Plan must follow Medicare rules. Medicare rules say that the maximum quantity of supplies for code A5120 is 150. This request is for supplies above that limit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Skin Barrier Wipes have not been met. Therefore, we decided that the Plan does not have to pre-approve 150 Skin Barrier Wipe or Swab (A5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full mouth debridement (D4355).

You asked the Plan to pre-approve the full mouth debridement. You say that cleanings are covered by your Plan so this service should be covered. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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. Please note that a full mouth debridement is not the same thing as a standard teeth cleaning or a periodontal deep cleaning of the gums, these are each separate and distinct services. Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
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 has not been proven to be helpful.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation in efficacy in the published literature. Therefore, the request is considered not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network counseling services provided to the enrollee on September 2, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have out of network benefits. Maximus administratively overturned this case because a Plan contract was not submitted for review. The Plan requested a reopen and submitted the appropriate contract.

The Plan is correct in this case. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network counseling services provided to the enrollee on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for dental services (D0120 and D1110) provided on January 6, 2020.
You asked the Plan to reimburse you for these services. You stated that you believe the $50 copayment was incorrect. The Plan denied your request. The Plan says per your DentaQuest contract, there is a $10 copayment for each preventative service. Maximus overturned the Plans denial and stated the Plan did not provide information to show you were made aware of the copayment expectation for each service. The Plan requested a reopen and provided copies for the enrollee DentaQuest benefit agreement and an Explanation of Benefits showing the cost of each service.
The Plan is correct in this case. 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. The Plan contract clearly states there is a $10 copayment for each service provided. Based on the claim submitted by your dental provider to the Plan, the $50 copayment was correct. Therefore, we decided that the Plan does not have to reimburse you for dental services (D0120 and D1110) provided on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on December 16, 2020.

You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says the request is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical indications.

We looked at the file and Medicare rules. The medical records provided show that the enrollee was last seen by the ordering provider in May 2019. There were no recent medical records provided to show that the enrollee had a recent injury, surgical procedure, or knee instability. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on December 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided from November 4, 2020, to November 11, 2020.

You asked the Plan to pay for the personal care services. You say that the home health care services were medically necessary. You say that not having what is prescribed by your doctor puts you in imminent danger. You also say that you are currently disabled and on a limited income. The Plan denied your request. The Plan says that procedure codes with a status indicator of "I" are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that procedure code T1019 - personal care services, per 15 minutes - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pay for the personal care services provided from November 4, 2020, to November 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from November 28, 2020, through November 29, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that you were in excruciating pain and it would not stop for ten (10) hours before your admission to the emergency room. The Plan denied your request. The Plan says your request is not medically necessary because your records show you do not have problems like this, requiring hospitalization. The Plan states you improved after overnight observation with intravenous hydration and were stable and ready to go home after one night in the hospital.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found as you were improving after being sent to observation, it was not likely that you would require hospitalization that would cross two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from November 28, 2020, through November 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870).

You asked the Plan to pre-approve the Vertiflex device. You say that included with this letter is the clinical documentation which supports these clinical findings and medical necessity for the procedure. The Plan denied your request. The Plan says this service is considered experimental and investigational as there are not enough studies on Vertiflex Superion to show it is safe and effective.

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 this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a frontal ethmoidectomy (31253).

You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the patient has tried antibiotics. In addition, the CT scan does not show evidence of sinus disease. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a frontal ethmoidectomy (31253).
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation does not support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services fifteen (15) hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or maintain your functional status. You are ambulating up to fifty (50) feet with minimal assistance. You can receive services 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.