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

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation
correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815) for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your
request. The Plan says the reason this request cannot be approved is because: the enrollee must have results of a
tissue sample taken for lab testing (biopsy) or other diagnostic testing that confirm the diagnosis of cancer. The
Plan states this testing might include blood tests, picture studies, clinical indications (symptoms), and an exam
done by the enrollee's doctor.

The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our physician reviewer
found the medical records provided are insufficient to support the presumptive diagnosis of ileocecal valve
carcinoma. The elements of the national coverage determination are not satisfied. The requested service cannot
be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization
imaging; skull base to mid-thigh (CPT code 78815) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee.

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the home health agency should follow patient driven groupings model instructions for claims.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted documentation does not include a RAP to verify the billed services and dates. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and the enrollee is a good candidate for the procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. Open laminectomy is the gold standard procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

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 you are being discharged from the SNF due to decreased participation in therapy.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown.

You asked the Plan to pre-approve the crown. You say that you would like this service to be approved. The Plan denied your request. The Plan says this service is not a covered benefit under your plan.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required
(quantity 2) for tooth #7 and #8 (CPT code D2950), and crown - porcelain/ceramic for tooth #7 (D2740).

You asked the Plan to pre-approve the dental services. You say that you would like a crown on tooth #8 due to
it being cracked. The Plan denied your request. The Plan says your benefit has been exhausted for the 2021
plan year.

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.

Records indicate you were previously approved for D2740 for tooth #8. Therefore, the
services requested for D2740 for tooth #7, exceeds your benefit limitation and has also been denied. The health
plan contract says crown - up to one (1) per calendar year. Benefit limited to codes: D2740/D2750.
Furthermore, D2950 is not listed as a covered benefit in your Dental Benefit Schedule. Therefore, we decided
that the Plan does not have to pre-approve core buildup, including any pins when required (quantity 2) for tooth
#7 and #8 (CPT code D2950), and crown - porcelain/ceramic for tooth #7 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered.

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 only one hospital discharge day management service is payable per patient per hospital stay.

We looked at the file and Medicare rules. The file shows that codes 99238 (hospital discharge day management, 30 minutes or less) was billed and was approved by the Plan. Code 99239 (hospital discharge day management, more than 30 minutes) billed was for the same inpatient stay and not separately payable. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is medically necessary. The Plan denied your request. The Plan says coverage criteria for a therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the 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.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgery services provided by a participating
provider.

You asked the Plan to waive the copayment for surgery services. You say that you should not have to pay
because it was not your fault. The Plan denied your request. The Plan says the correct copayment has been
applied.

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 $200
copayment for outpatient surgery.

You have been asked to pay a $200 copayment for surgery services. Surgery services fall within the outpatient
surgery 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 surgery services provided
by a participating provider

Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit
Maximus to make a decision based on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom protective cover for a prosthesis (L5705).

You asked the Plan to pre-approve the custom cover. You say that the enrollee uses a prosthetic and requires
the weatherproofing custom protective cover. The Plan denied your request. The Plan says the L5705 was
denied for not being medical in nature.

The Plan must follow Medicare rules. Medicare rules say that code L5705 will be denied as not reasonable and
necessary for a prosthesis.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the custom cover have not been met. Therefore, we decided that the Plan does not have to pre-approve
the custom protective cover for a prosthesis (L5705).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a basic lymphedema pump to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a basic lymphedema pump. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network suppliers available to the enrollee that can provide the same care and services being requested.

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 basic lymphedema pump 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 power scooter.

You asked the Plan to pre-approve a power scooter. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested power scooter.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be approved without a physician order. 

The file does not contain a physician order. The medical records only document a recommendation for a wheeled walker with a seat and for you to continue to wear your knee brace. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.

You asked the Plan to pre-approve special supplemental benefits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. While the Plan offers supplemental benefits covering certain services for the chronically ill, the documentation does not support that you meet criteria for these services. 

The services you have asked the Plan to pre-approve are only covered under certain circumstances. The documentation and medical records do not support that you have a diagnosis where these services would be covered. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).

You asked the Plan to pre-approve the special supplemental benefits. You say that the benefits are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. These services are not covered by Medicare. Since these services are not covered by Medicare, the plan's rules apply in this case. 

We looked at the file and the plan's rules. The documentation shows that the enrollee does not have any of the qualifying diagnoses, nor does the enrollee require intensive medical management. The enrollee is not at high risk for hospitalization. Based on this information, we decided that Medicare rules for coverage of the special supplemental benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing (95938) and nerve conduction studies (95908).

You asked the Plan to pay for somatosensory testing and nerve conduction studies. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. 

We looked at the file and Medicare rules. The file shows that the enrollee was an inpatient at the time of service, but the services at issue were not reported with POS 21. Based on this information, we decided that Medicare rules for coverage of somatosensory testing and nerve conduction studies have not been met.

Therefore, we decided that the Plan does not have to pay for somatosensory testing (95938) and nerve conduction studies (95908).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective.

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed with side rails and mattress.

You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee's current bed is contributing to the decline of health and the caretakers are not able to give the standard of care the enrollee deserves. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed with side rails and mattress.
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 there is no evidence of an ongoing, daily, inpatient skilled therapy needs.

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 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services.

You asked the Plan to waive the copayment for the lab services. You say that you do not remember having a lab service on that date. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this lab service ($3.36) is less than your copayment obligation, you are responsible for the full allowed amount.

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 $5 copayment for lab services.

Records show that you saw your gastroenterologist. During that visit, the medical records show that the nurse practitioner in the office drew blood and sent it to the lab for processing. You have been asked to pay a $5 copayment for the lab services. 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 lab services.