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

Wedecided that the Plan does not have to pre-approveProlia for the enrollee.You asked the Plan to pre-approveProlia. You say that this drug is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteriaare not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for Prolia.The Maximus Physician Reviewer determined that the use of Prolia is supported in this case. The reviewer found the requested use of Prolia is FDA-approved for the enrollee's diagnosis, and that the documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary.The Plan requested a reopen stating that Prolia is indicated for increasing bone mass in men at high risk for fracture receiving androgen deprivation therapy for non-metastatic prostate cancer. The Plan notes that the enrollee has metastases to the bone, and consequently he is only appropriate for the Xgeva formulation of denosumab, according to NCCN Guidelines for prostate cancer. The medical records show the enrollee has a diagnosis of prostate cancer with multiple lytic and blastic metastases to bone. The provider writes that the enrollee will need denosumab for his castrate sensitive disease though at only 60mg every 6 months. The Plan is correct in this case. While Prolia and Xgeva both contain Denosumab, each is used for a different purpose. The Xgeva formulation of Denosumab is indicated for prophylaxis of skeletal-related events in patients with bone metastases from solid tumors.Medicare criteria for Prolia are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable wireless pulmonary artery pressure sensor
with delivery catheter, including all system components (CPT Codes: C2624 and transcatheter implantation of
wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and
calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological
supervision and interpretation, and pulmonary artery angiography, when performed (33289).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has
been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not
met, since the device should still be considered experimental or investigational.
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 implantable wireless pulmonary artery pressure sensor with delivery catheter, including all
system components (CPT Codes: C2624 and transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart
catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary
artery angiography, when performed (33289).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be stabilizing but requires additional acute care services to manage lung infiltrates and leukocytosis, which can safely be administered in the current setting. The patient does not require complex wound care or other services at the LTACH that are not already available at the current setting. There are no services at the LTACH that the patient requires that are not already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when it is more appropriate.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-approveLTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuous glucose monitor supplies to be provided by a non-preferred provider.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says your benefit does not cover diabetic supplies from a local or mail order pharmacy.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that supplies to monitor your blood glucose may be limited to supplies from select manufacturers.The file shows that a Freestyle Libre sensor was requested. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the itemsat issue in this appeal. We found no exception that would require the Plan to pre-approve these items from the requested provider.Therefore, we decided that the Plan does not have to pre-approvecontinuous glucose monitor supplies to be provided by a non-preferred provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound examination provided on August 1, 2020.You asked the Plan to waive the copayment forultrasound. You say that this ultrasound is covered by insurance and you should not have a copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 copayment for in-network ultrasound. However, the Plan has only asked you to pay the $45 X-Ray copayment for this claim, which is lower than the applicable copayment for an ultrasound.You have been asked to pay $45, which is less than the $275 copayment for ultrasound. Ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have towaive the copayment foran ultrasound examination provided on August 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe four additional extractions provided on July 1, 2020.You asked the Plan to pay fortheadditional extractions. You say that many dentists were not open for business due to the pandemic, and you could not wait any longer for these extractions.The Plan denied your request. The Plan says your extractions benefit has been exhausted.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, extractions are limited to two procedures per calendar year. The record shows that you received six extractions on July 1, 2020, two of which were covered by the Plan, and your extractions benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe four additional extractions provided on July 1, 2020
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armour Thyro Tab 90mg.

You asked the Plan to pre-approve the medication. You say that the medication is necessary.The Plan denied your request. The Plan says the plan benefits say this members plan does not have a Medicare Part D benefit or separate pharmacy benefit managed by the Plan. The Plan states the benefit covers those drugs covered under traditional Medicare Part A and Part B.

 The Plan states Armour Thyro Tab 90mg are to be obtained via member's pharmacy benefit and is not Medicare covered under the Part A or B 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 Armour Thyro Tab 90mg.

Benefits for the medicationmay 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 18, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advanced.Medicare rules saythat 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a safety belt/pelvic strap, expandable controller, expandable harness, electronics.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the approved power options come with their own switches.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found your right upper extremity strength and function are sufficient for the patient to control any power options through their own individual switches. The documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The requested E0978 safety belt/pelvic strap exceeds your medical need as this is already included in the power wheelchair. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a safety belt/pelvic strap, expandable controller, expandable harness, electronics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemetal artifact reduction (MAR) to be performed at an out-of-network facility.You asked the Plan to pre-approvethe medical services. You say that the member needs this service in order for you to test their stress fractures and impingement.The Plan denied your request. The Plan says there are in-network providers available to provide the service.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-approvemetal artifact reduction (MAR) to be performed at an out-of-network facility.
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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's
care needs can be met at a lower level of care (ex. SNF/SAR, HHS).
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.

You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires this level of care to achieve a safe and sustainable discharge.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.

The Plan must follow Medicarerules. 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 in this case, ongoing care needs include intravenous antibiotics, intravenous antifungals, surveillance laboratory studies, scheduled hemodialysis, colostomy care, hemovacuum care, wound care, and therapy services. 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-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 4, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF)
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our 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 does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
COVID-19 pneumonia and atrial fibrillation. Medical problems are stable. There are no identified problems
that need inpatient medical management. 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. The medical record supports a need for physical and occupational
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable
expectation that you would be able to fully participate in and benefit from the intensive rehab therapy program
provided in an IRF.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approved CT scan of the soft tissue of the neck. We decided that the Plan does not have to pre-approved CT scan of the head or brain. 

You asked the Plan to pre-approved CT scan of the soft tissue of the neck. You say that the requested CT services should be covered because the enrollee has a history of melanoma and because poorly differentiated squamous cell has the potential to metastasize and could have life threatening consequences.The Plan says that rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 15830) provided on July 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.
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 15830 is "Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy". We asked our coding 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 services. Our reviewer says that the use of CPT code 15830 is not supported by the records provided. Our coding reviewer found that the operative report documents muscle separation repair. No excision of excessive skin or subcutaneous tissue was documented, therefore this code cannot be verified. We looked at this coder'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 pay for the services (CPT 15830) provided on July 27, 2020.