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

We decided that the Plan does not have to pre-approve an endoskeletal system, below knee addition.
You asked the Plan to pre-approve an endoskeletal system, below knee addition. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a current prosthetic socket that was approved and provided on October 2020. Your current prosthetic socket serves the same purpose as the requested below the knee addition. Review of the file does not support that your current item is damaged beyond repair and cannot be reused for the approved socket. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal system, below knee addition.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for outpatient mental health care
provided from August 10, 2020 to August 21, 2020.
You asked the Plan to waive these copayments. You say that you do not agree with this cost share. The Plan
denied your request. The Plan says these copayments were charged based on the services provided and the Plan
contract agreement. Maximus partially overturned the Plans denial reducing the copayments from $440 to
$400. The Plan requested a reopen and provided additional information stating the figure of $440 was sent in
error and that the case file should have stated the total amount was $400, which is what Maximus agreed with.
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 $40
copayment for each outpatient mental health visit.
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 copayments charged for outpatient mental health care provided from August 10,
2020 to August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation.
You asked the Plan to pre-approve transcranial magnetic stimulation. 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 retreatment(s) may be considered medically
reasonable and necessary for patients who meet specific criteria.
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 transcranial magnetic stimulation. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based on the
information provided this enrollee does meet the clinical criteria for the use of TMS therapy utilizing LCD
L34998 as records submitted showed this enrollee had not specifically seen a physician MD or DO who
examined the enrollee and reviewed the record. The enrollee's PHQ 9 of 15 does not meet the diagnosis criteria
for Major Depressive Disorder, Recurrent, Severe.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transcranial magnetic stimulation have not been met. Therefore, we decided that
the Plan does not have to pre-approve transcranial magnetic stimulation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81105, 81112, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81350, 81355, 81400, 81401 and 81479) provided January 4, 2021.

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 

We looked at the file and Medicare rules. The genetic testing panel was billed with multiple unbundled codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.

Therefore, we decided that the Plan does not have to pay for genetic testing (81105, 81112, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81350, 81355, 81400, 81401 and 81479) provided January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings have been covered in the past and the ones you have currently are older than 6 months. The Plan denied your request. The Plan says Medicare only covers these if needed to treat a qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar stabilization device procedure.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). You say that the enrollee needs this device for pain relief. The Plan denied your request. The Plan says there are not enough studies on the device 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. 

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 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is 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 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interlaminar stabilization device procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. 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 the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients that meet specific criteria. 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 RFA. Our reviewer says that the
services are not medically necessary. Our physician reviewer found this request is not in keeping with established algorithms. The RFA failed to produce sustained relief. It should not be repeated. The request 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart computed tomography (CT) with quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). You say that this CT is medically necessary. The Plan denied your request. The Plan says the CT is considered screening, is not a covered service and is denied.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, CT, heart, without contrast material, with quantitative evaluation of coronary calcium (75571), is being requested solely for screening purposes. Medicare does not cover this test. Therefore, we decided that the Plan does not have to pre-approve a heart computed tomography (CT) with quantitative evaluation of coronary calcium.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 7, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not include a signed physician order nor records indicating that these tests were intended by the treating physician.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 19, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspect or documented cardiovascular disease. We looked at the file and Medicare rules. The service at issue is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from May 1, 2021 to August 10, 2021. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you want to appeal the denial. The Plan denied your request. The Plan says you do not qualify for the special supplemental benefit for chronic diseases.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of coverage for special supplemental benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide.
You asked the Plan to pre-approve the inhalation of nitrous oxide. You say that you cannot be seen or treated at the dentist without this medication due to your anxiety. You say that you were advised this was a covered service and you shouldn't have any issues. The Plan denied your request. The Plan says the service 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 the inhalation of nitrous oxide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement joystick (E2374), a bus cable, captain seat, and 19" seat base (all coded K0108), and repair costs (K0739).

You asked the Plan to pre-approve a replacement joystick, a bus cable, captain seat, and 19" seat base with repair costs. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the enrollee has not used the equipment to be replaced for its reasonable useful lifetime.

The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. 

We looked at the file and Medicare rules. In this case, you are requesting replacement components for a power wheelchair received by the enrollee in 2019. Therefore, the requested replacements are for items that have not outlasted their reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a replacement joystick, a bus cable, captain seat, and 19" seat base with repair costs have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement joystick (E2374), a bus cable, captain seat, and 19" seat base (all coded K0108), and repair costs (K0739).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desmopressin nasal spray.

You asked the Plan to pre-approve Desmopressin nasal spray. You say that the enrollee has been on this medication for 4 years. The Plan denied your request. The Plan says this drug is not covered.

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 Desmopressin nasal spray.

Benefits for Desmopressin nasal spray may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiothoracic surgery evaluation to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a cardiothoracic surgery evaluation to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that Plan does not have to pay for a wheelchair purchased from Amazon.com on March 18, 2021.
You asked the Plan to pay for durable medical equipment purchased online. You say that the Plan should pay for this wheelchair. The Plan denied your request. The Plan says durable medical equipment purchased out of network from a provider who is not an eligible Medicare provider is not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Durable medical equipment purchased privately through agents such as Amazon are not eligible for coverage by your Medicare governed health plan. Therefore, we decided that the Plan does not have to pay for a wheelchair purchased from Amazon.com on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have been met.
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 physical therapy to be provided by an out-of-network (OON) provider.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia and pulmonary
fibrosis and was transferred to skilled nursing on 7/2/21. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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.