Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that your physician told you to get the requested compression stockings. The Plan denied your request. The Plan says the requested item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied your request. The Plan says the service at issue 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 Plan does not have to pre-approve a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for 16 miles for a total of 66 miles
coverage for routine transportation trips.
You asked the Plan to pre-approve additional mileage for 16 miles for a total of 66 miles coverage for routine
transportation trips. You say that you need to see your neurologist for your medical condition, which is
multiple sclerosis. The Plan denied your request. The Plan says your benefit only allows 48 one-way trips
whereas each one-way trip must not exceed 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.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional mileage for 16 miles for a total of 66 miles coverage for routine
transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1851).
You asked the Plan to pre-approve a knee brace. You say that the requested item is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for a knee brace have 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 a knee brace. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found
that the enrollee has degenerative joint disease of the knee. There is not enough information in the records to
justify the use of a knee brace. There is no instability documented.
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 knee brace have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee brace (L1851).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and
contents (72141).
You asked the Plan to pre-approve the MRI. You say that you have severe medical issues, and the MRI is
necessary due to severity of pain. You have suffered in pain for weeks which is now impacting the daily
function of your heart. The Plan denied your request. The Plan says this request does not meet the criteria for
medical necessity.
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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee had a laminectomy in 2020 and has pain. The neurologic
examination does not indicate any deficit. The record indicates that surgery is contemplated but no surgical
consultation is available for review. The medical record as submitted does not support the medical necessity
and reasonableness, as defined by Medicare rules, of the requested service. 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 not been met. Therefore, we decided that the Plan does not have
to pre-approve the magnetic resonance imaging, spinal canal and contents (72141).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377, E2313) and power seat elevation feature (E2300).
You asked the Plan to pre-approve the expandable controller and power seat elevation feature. You say that this request is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to control the power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that an expandable controller and power seat elevation feature are subject to the criteria listed 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 the expandable controller and power seat elevation feature. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found the documentation does not reveal that the patient requires 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.). The patient does 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 patient's strength in the upper extremities supports that the patient can control any power options through their own individual switches. In addition, the power seat elevation feature is statutorily not covered by Medicare because it is not primarily medical in nature. This item will not be covered. 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 expandable controller and power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377, E2313) and power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two prefabricated abutments (D6057 x2) and two
abutment supported porcelain/ceramic crowns (D6058 x2).
You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain/ceramic
crowns. You say that the brochure you were shown outlining what is covered under the Plan's dental coverage
does not have any stipulation regarding the coverage of implants. The Plan denied your request. The Plan says
you became effective under this dental plan on January 1, 2021, and you have not been continuously covered
by this dental plan for more than 24 months. The Plan also says that the teeth were missing prior to your dental
coverage becoming effective on January 1, 2021.
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 initial installation of implants, full
or partial dentures or fixed bridgework to replace a tooth or teeth extracted prior to your effective date are
excluded from coverage. The contract says that this exclusion will not apply for any member who has been
continuously covered under the Plan's dental for more than 24 months. The record shows that you did not
become effective under this dental plan until January 1, 2021, and teeth #4 and 14 were extracted prior to
January 1, 2021. Therefore, we decided that the Plan does not have to pre-approve two prefabricated abutments
(D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for office visits and duplex scans for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-network.
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 a referral out-of-network for office visits and duplex scans for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you are replacing the old inserts with the new.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-approvefoot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient rehabilitation stay. You say that admission to IRF is required, as the enrollee's current needs cannot safely be met at a lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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 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. skilled nursing facility/subacute rehab). 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the 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 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF on 6/7/21 after being hospitalized for a fall at home, rhabdomyolysis and a urinary tract infection. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a contact guard to minimal assist level with functional mobility including gait to 140 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea specialized wound treatment for the enrollee.You asked the Plan to pre-approvea specialized wound treatment. You say that this treatment was medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria are 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 PuraPly AM antimicrobial wound matrix. The Maximus Physician Reviewer determined that PuraPly AM is indicated for the wound management in this patient. This wound had developed post right transmetatarsal amputation and has been already debrided to remove necrotic tissues.The Plan requested a reopen and argues the clinical history shows a contraindication of active osteomyelitis and the continued improvement of the wound with standard wound care alone.The medical records show the enrollee has a history of type 2 diabetes, with osteomyelitis involving the 3rd metatarsal and proximal phalanx. The enrollee underwent a transmetatarsal amputation and had a persistent anterior wound. On December 21, 2020, the orthopedic surgeon documented that the wound was continuing to granulate in. The surgeon documented that he thought the enrollee would benefit from PuraPly AM to promote healing and prevent recurrent infection.Our Medical Director has concluded that the Plan is correct in this case. PuraPly AM Wound Matrix is a native, cross-linked extracellular matrix plus polyhexamethylene biguanide antimicrobial barrier, and is intendedfor the management of acute and chronic wounds. The documentation in the case file does not support that the enrollee had a failed response, defined as an ulcer or skin deficit that failed to respond to documented appropriate wound-care measures, had increased in size or depth, or had not changed in baseline size or depth and had no indication that improvement was likely (such as granulation, epithelialization or progress towards closing).Medical necessity has not been established. 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 specialized wound treatment have not been met.Therefore, we decided that the Plan does not have to pre-approvea specialized woundtreatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound therapy provided from December 9, 2020, to December 30, 2020.
You asked the Plan to pay for ultrasound therapy provided by a chiropractor. You say that you were told the ultrasounds were covered. The Plan denied your request. The Plan says this service is not covered under any normal circumstances.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for ultrasound therapy provided from December 9, 2020, to December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean addition, endoskeletal system, below knee, alignable system (L5910) for the enrollee.You asked the Planto pre-approvethis item. You say that this is medically necessary.The Plan denied your request. The Plan says that this cannot be used with this preparatory prosthesis.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 item. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. The enrollee has undergone a prosthetic evaluation with functional level assessment. The documentation does not support that an alignable system is medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this item.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 item have not been met.Therefore, we decided that the Plan does not have to pre-approvean addition, endoskeletal system, below knee, alignable system (L5910) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vascular study provided on January 26, 2021.
You asked the Plan to waive the copayment for the vascular study. You say that this is not a copayment for a doctor's visit, and you don't know what this charge is for. You say that this is a lab for an MRI, and you should not have been charged $45. The Plan denied your request. The Plan says the copayment applied correctly.
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 a $45 copayment for diagnostic procedures and tests from an in-network provider.
You have been asked to pay a $45 copayment for the vascular study. The vascular study 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 to waive the copayment for the vascular study provided on January 26, 2021.