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

We decided that the Plan does not have to pay-for continued coverage of the CPAP device (E0601) and humidifier (E0562) provided September 9, 2020.
You asked the Plan to pay-for CPAP device and humidifier. You say that this device is medically necessary. The Plan denied your request. The Plan says rules for continued coverage of the CPAP device have not been met.
The Plan follows Medicare rules. Medicare rules say that continued coverage of the CPAP device is 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 CPAP device and humidifier. Our reviewer says that the requested items are not medically necessary and reasonable. Our physician reviewer found continued CPAP is considered not medically necessary. The medical records do not include evidence of clinical follow-up to document use and benefit from CPAP. There is no compliance information or device download. Since coverage cannot be provided for CPAP device, the related humidifier is non-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 CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pay-for continued coverage of the CPAP device (E0601) and humidifier (E0562) provided September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the approved power options come with their own switches.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically necessary to accommodate any of the functions listed in the LCD. 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the submitted records do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We are dismissing your case. The records show that the enrollee's requested prior authorization for custodial care services. However, Maximus has learned that the enrollee has since passed away. Therefore, the issue regarding prior authorization for custodial care services is now moot. That is why we are dismissing this case.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 surgical tooth extractions (D7210).

You asked the Plan to pre-approve the surgical extractions. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the requested extractions are 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 5 surgical tooth extractions (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the PCD is not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950).
You asked the Plan to pre-approve a core buildup. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says this service is not covered under your supplemental 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 core buildup (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a muscle transfer (23395) provided on October 23, 2020.
You asked the Plan to pay for a muscle transfer. You say that this procedure is documented. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 23395 is muscle transfer, any type, shoulder or upper arm; single. 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 a muscle transfer. Our reviewer says that this code is not supported. Our physician reviewer found the operative note describes the performance of a biceps
tenodesis, described by CPT code 23430. The operative note does not describe a muscle transfer. 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 muscle transfer have not been met. Therefore, we decided that the Plan does not have to pay for a muscle transfer (23395) provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you from February 4, 2020 to February 6, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services rendered to you from February 4, 2020 to February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total right reverse shoulder arthroplasty surgery (23430, 23472).

You asked the Plan to pre-approve an acute inpatient hospital admission. You say that an acute inpatient hospital admission is medically necessary. The Plan denied your request. The Plan says an acute inpatient hospital admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights.

In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 an acute inpatient hospital admission. Our reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer found that in this case, the enrollee was scheduled to have a shoulder arthroplasty surgery. The medical records provided do not indicate that there is a reasonable expectation of a length of stay spanning two or more midnights. The enrollee can be admitted for a period of observation, and if necessary, converted to an inpatient admission. The elements of the coverage rule 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 an acute inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total right reverse shoulder arthroplasty surgery (23430, 23472).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH).
The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long-term care needs.
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection provided on January 16, 2020.
You asked the Plan to waive the coinsurance for the injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a Part B injection on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on
January 16, 2020. You have been asked to pay a 20% coinsurance for the injection, totaling $1755.36. The injection falls within the Medicare Part B prescription drugs 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 coinsurance for the injection provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 31, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on January 7, 2021.
You asked the Plan to pay for the dental service. You say that your front tooth broke. You say that it had to be pulled. You also say that some of this should be covered. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.
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 pay for the partial upper denture (D5213) provided on January 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical information submitted reveals that all restorative rehab goals are met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no required skilled nursing services identified in the records. The documentation does not support that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the required respite services can be safely received in a different setting.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not require skilled nursing or therapy services on a daily 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services described by current
procedural terminology (CPT) codes 97012, 97110, and 99203 provided on January 11, 2021, and January 13,
2021.
You asked the Plan to pay for CPT codes 97012, 97110, and 99203. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says these CPT codes are not
covered when billed by a chiropractor.
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 services at issue were not manual manipulation of the spine. CPT codes 97012,
97110, and 99203 are not covered when billed by a chiropractor. Therefore, we decided that the Plan does not
have to pay for the non-covered chiropractic services described by current procedural terminology (CPT) codes
97012, 97110, and 99203 provided on January 11, 2021, and January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychiatric treatment (90791, 90834) provided on November 13 and December 3, 2020.
You asked the Plan to pay for outpatient psychiatric treatment. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient psychiatric treatment (90791, 90834) provided on November 13 and December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor (CGM) provided on October 12, 2020.
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a final determination within the allotted time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan has denied this claim due to missing/incomplete/invalid procedure code(s) and that the claim/service lacks information or has submission/billing errors. The errors that the Plan says that the claim have are not identified in the documentation provided to Maximus. Medical records, physician order, and a proof of delivery were supplied by the provider in the documentation. The Plan's denial is not substantiated. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) provided on October 12, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection, 10 mg/ml.
You asked the Plan to pre-approve a Euflexxa injection. You say that this medication is necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa injection. Our reviewer says that the Euflexxa injection is not medically necessary. Our physician reviewer found the medical records provided do not indicate that the enrollee has tried and failed the required drugs. The reviewer found that the medical records provided do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Euflexxa, is not medically 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 a Euflexxa injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Euflexxa injection, 10 mg/ml.