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

We decided that the Plan does not have to pay forthe ambulance services provided. on February 15, 2020.You asked the Plan to pay forthe ambulance services. You say that you fell and needed assistance getting back up.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 February 15, 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 forthe ambulance services provided on February 15, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan does not have to pay forbitewing x-rays provided on June 17, 2020.You asked the Plan to pay forbitewing x-rays provided on June 17, 2020. You say that these dental services should be covered by the Plan.The Plan denied your request. The Plan says the benefit was exhausted at the timeof service. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the dental benefit allows coverage for bitewing x-rays once in a twelve-monthperiod. Plan covered bitewing x-rays on June 18, 2019. You were not eligiblefor this benefit again until after June 18, 2020. Therefore, x-rays taken June 17, 2020 were not yet eligible for coverage.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.Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided was not available for coverage at the time it was rendered.Therefore, we decided that the Plan does not have to pay forbitewing x-rays provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebone replacement graft for ridge preservation (D7953).You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvebone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveretainer crowns (D6740) for tooth number's 2, 4, and 5 and a pontic (D6245) for tooth number 3.You asked the Plan to pre-approvethe retainer crowns and pontic. You say that you would like reconsideration because you would like non-removable prosthesis.The Plan denied your request. The Plan says your records do not indicate or support any specific physical or psychological condition(s) that prevent you from using a removable ProsthesisMedicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rulesapply in this case. The Plan covers the retainer crowns and pontic when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the retainer crowns and pontic. Our reviewer says that the Office Reference Manual provides that for fixed bridgework, authorizations for prosthesis do not meet criteria if appropriate documentation is not received documenting physical or neurological disorders precluding the placement of a removable prosthesis. Our physician reviewer found there is no provided documentation as to any physical or mental disability that you are suffering from.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontic have not been met.Therefore, we decided that the Plan does not have to pre-approveretainer crowns (D6740) for tooth number's 2, 4, and 5 and a pontic (D6245) for tooth number 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe connective tissue graft procedure (D4273).You asked the Plan to pre-approvethe connective tissue graft procedure (D4273). You say that you need this surgery done right away or you may lose your teeth.The Plan denied your request. The Plan says the service is not a covered benefit.Medicare generally does notcover 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 orservices are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe connective tissue graft procedure (D4273)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom-fabricated back cushion, seat back, attendant
control, gel arm pads and foot plates.

You asked the Plan to pay for the wheelchair accessories. You say that you would like reconsideration because
the member has poor trunk control, lack of balance and extreme muscle weakness. The Plan denied your
request. The Plan says the member does not meet Medicare coverage criteria for these accessories.

The Plan follows Medicare rules. Medicare rules say that 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 wheelchair accessories. Our reviewer
says that there is no documentation that the member meets the LCD criteria for these accessories. Based on the
medical records provided there is no documentation that the custom-fabricated back cushion is medically
reasonable and necessary. Our physician reviewer found based on the medical records provided there is no
documentation that the member is unable to operate the power wheelchair. Records specifically indicate he is
able to operate the power wheelchair.

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 wheelchair accessories have not been met. Therefore, we decided that the
Plan does not have to pay for a custom-fabricated back cushion, seat back, attendant control, gel arm pads and
foot plates.
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 this is for fall prevention. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve aquatic therapy. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy 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 a heel protector (E0191).

You asked the Plan to pre-approve a heel protector. You say that this is a necessity that 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 pre-approve a heel protector (E0191).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron.

You asked the Plan to pre-approve Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron. You say that the requested Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron are medically necessary. The Plan denied your request. The Plan says the requested Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron are not medically necessary.

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 Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron. Our reviewer says that the requested Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron are not medically necessary. Our physician reviewer found the enrollee is diagnosed with EGFR mutant and PD-L1 positive, ALK and ROS-1 negative metastatic non-squamous NSCLC.

FDA approved for treatment (single agent) of metastatic NSCLC in adults with disease progression during or following platinum-containing chemotherapy (patients with EGFR or ALK genomic aberrations should have disease progression on approved therapy for EGFR or ALK genomic tumor mutations prior to receiving atezolizumab). This enrollee has progressed on prior carboplatin and paclitaxel with osimertinib.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, Atezolizumab, Fosapreepitant, and Palonosetron.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy (OT) (97165).

You asked the Plan to pre-approve the OT Evaluations. You say that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says the medical necessity criteria
for occupational therapy is not met.

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 OT Evaluations. 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 requested additional therapy is not generally accepted as specific
and effective therapy for the patient's condition per the submitted documentation. The documentation does not
indicate that the patient requires the unique skills of a professional therapist to safely and effectively provide
treatment, or that the services can be safely and effectively performed only by a therapist or under the
supervision of a therapist. The documentation does not support objective therapy documentation indicating the
patient will be participatory in therapy. The requested services are not part of a maintenance program and the
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or
deliver a program to maintain the patient's current condition or to prevent or slow further 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 the OT Evaluations have not been met. Therefore, we decided that the Plan does
not have to pre-approve occupational therapy (OT) (97165).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography, abdomen and pelvis.

You asked the Plan to pre-approve a computed tomography, abdomen and pelvis; with contrast material(s) (74177). You say that the enrollee is due for an annual CT scan. The Plan denied your request. The Plan says the enrollee has completed a series of CT scans for 3 consecutive years following treatment.

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, abdomen and pelvis; with contrast material(s) (74177). Our reviewer says that the service is not reasonable or medically necessary. Our physician reviewer found deny per NCCN guidelines anal ca 1.2021 page ANAL-3, CT scans are approved for 3 years only. 

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, abdomen and pelvis; with contrast material(s) (74177) have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography, abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.

You asked the Plan to pre-approve the dental service. You say that your dentist is recommending that you see an oral surgeon to have your tooth extracted. You say that you were informed that you are eligible for 1 extraction. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist.

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. Dental services performed by an oral surgeon are not covered. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 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. Your care needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the lead wires.

You asked the Plan to pay for 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 replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary.

We looked at the file and Medicare rules. The file shows that the TENS device was rendered. Replacement lead wires more often than every 12 months is not necessary. Therefore, we decided that the Plan does not have to pay for the lead wires.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for this service was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99222).
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
enrollee. 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 spacer remains experimental. More research is needed to show safety and efficacy of the device.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine provided to the enrollee.

You asked the Plan to pay for vaccines under Medicare Part B. You say that this claim should be paid. The
Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B. In the absence of
injury or direct exposure to illness, Medicare does not pay for or provide vaccines under Medicare Part B. The
Plan follows the same rules. The records do not show that the enrollee was injured or directly exposed to any
illness related to vaccines under Medicare Part B. Therefore, we decided that the Plan does not have to pay for
the tetanus vaccine provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.