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

We decided that the Plan has to pre-approve a group 2 power wheelchair (K0823).
You asked the Plan to pre-approve a group 2 power wheelchair. You say that this device is medically necessary. The Plan denied your request. The Plan says that the requested wheelchair is not medically necessary and reasonable.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker, cane or manual wheelchair, and the patient is capable of safely operating the requested PMD. 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 group 2 power wheelchair. Our reviewer says that the requested wheelchair is medically necessary and reasonable. Our physician reviewer found the enrollee is a 79-year-old woman who is wheelchair-bound with post-polio syndrome. In this case, the enrollee does have a personal mobility deficit that impairs participation in MRADLs. In addition, the enrollee has not used a manual wheelchair in 10 years due to a lack of arm strength so a walker, cane or manual wheelchair would not be appropriate in this situation. The records support that the patient can safely operate a PMD. Finally, the LCD criteria for a group 2 PMD have been met in this case, and that the wheelchair is appropriate for the enrollee's weight. 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 group 2 power wheelchair have been met. Therefore, we decided that the Plan has to pre-approve a group 2 power wheelchair (K0823). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (lift chair) purchased from a retail store on March 17, 2020.
You asked the Plan to pay for lift chair. You say that you are requesting reimbursement for this item. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this lift chair was purchased from a retail store that is not a Medicare certified provider.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. This lift chair was purchased from a provider that is not enrolled in the Medicare program, and is therefore not payable. Based on this information, we decided that Medicare rules for coverage of lift chair have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (lift chair) purchased from a retail store on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for genetic testing provided on September 3, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost was applied per the Plan contract rules. Maximus overturned the Plans denial. The Plan requested a reopen and stated that you did not have prior authorization for this testing and the amount charged is clearly stated in the contract.
The Plan is correct in this case. 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 genetic testing and prior authorization is required. 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 cost share charged for genetic testing provided on September 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $121.53 copayment charged for a sleep study provided on October 9, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement. Maximus overturned the Plans denial because a Plan contract was not submitted for review. The Plan requested a reopen and submitted the required Plan contract information.
The Plan is correct in this case. 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 $0 to $150 for Medicare covered outpatient diagnostic services. You have been asked to pay the correct amount based on your contract with the Plan and claim submitted by your provider, which resulted in a copayment of $121.53. 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 or reduce the $121.53 copayment charged for a sleep study provided on October 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says there is no indication that the enrollee has tried and failed zoledronic acid.
The Plan also says there is no indication that the enrollee has had an osteoporosis-related fracture.

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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found there is no evidence that the enrollee has a fracture, bone cancer or hypercalcemia. The reviewer found that while the enrollee may have GERD, there is no evidence that the enrollee has actually tried and been intolerant of oral bisphosphonates. Therefore, the reviewer found that the requested Prolia is not shown to be compliant with step-therapy requirements. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.

You asked the Plan to pre-approve additional transportation trips. You say that you need these services to visit
your providers for medical attention. The Plan denied your request. The Plan says you have utilized the
maximum number of transportation trips allowed per year.

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. The Plan covers a maximum of 40 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional transportation trips.
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. The Plan denied your request. The Plan says the enrollee could receive care in another setting.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for bilateral lower extremity weakness.
Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup procedure (D2950).

You asked the Plan to pre-approve the core buildup. You say that this service is necessary and requested by your dental provider. You cannot afford this service out of pocket.The Plan denied your request. The Plan says this service is not covered by the Plan's supplemental dental 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 procedure (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the crown (D2740), and core build up (D2950)
provided on January 12, 2021.

You asked the Plan to reimburse more for the dental services. You say that you were given an estimate of
$1,290 for the services you received. You say that your dental plan accepted $883. You say that you signed a
financial fee estimate. You say that you feel you should only be responsible for $293. The Plan denied your
request. The Plan says there is a 50% coinsurance for major dental services. The Plan also says there is a $100
annual deductible.

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 and the services are listed as covered,
there is a 50% coinsurance that applies. There is also a $100 deductible annually that applies.
TOTAL: $491.50

The record shows that you paid the provider $700 prior to receiving the services. The record shows that the
Plan requested that the provider send you are check for a refund of $208.50. Therefore, we decided that the
Plan does not have to reimburse more for the crown (D2740), and core build up (D2950) provided on January
12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcatheter implantation of a wireless pulmonary artery pressure sensor, CardioMEMS device (33289, C2624).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient has a history of Class III Congestive Heart Failure (CHF) and a recent admission for decompensated CHF. He is maintained on medical and diuretic therapy. Published Food and Drug Administration (FDA) indications for use of a CardioMEMS device based on published data from the CHAMPIONS Trial include the New York Heart Association (NYHA) Class III CHF and recent hospitalization for CHF, but the device is not recommended for implantation on patients with a body mass index (BMI) of >35 kg/m2 and chest circumference greater than 165 cm.

The patient's current BMI is reported as 41.18 kg/m2 and his chest circumference is not noted in the provided clinical data. Based on the published FDA indications for CardioMEMS implantation, the enrollee at this time would therefore not meet the criteria for medical reasonableness or necessity in the applicable CMS Section 1862(a)1 (A) rule, given his significantly elevated BMI, unless the chest circumference data is appropriate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter implantation of a wireless pulmonary artery pressure sensor, CardioMEMS device (33289, C2624).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT), abdomen and pelvis.

You asked the Plan to pre-approve a computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions (74178). You say that the CT is medically necessary and recommended from the radiologist. The Plan denied your request. The Plan says that a CT of the pelvis is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions (74178). Our reviewer says that the CT is medically reasonable and necessary. Our physician reviewer found in this case the enrollee has had an ultrasound that demonstrates a right renal cortical lesion and also a left parapelvic lesion. The prescriber has submitted a statement that the enrollee also has intermittent chronic abdominal and pelvic pain. The enrollee has a family history of renal cancer. The available information is sufficient to establish the medical necessity and reasonableness of the requested service. The elements of the coverage rule are satisfied. The requested service is 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 a computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions (74178) have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT), abdomen and pelvis.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a continued requirement for skilled nursing.

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 the enrollee does not have documented skilled nursing needs. As such, ongoing home health nursing services are not shown to be medically necessary or reasonable.

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 continued home health services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the heel stabilizer and ankle-foot orthosis provided on April 24, 2020.
You asked the Plan to pay for the heel stabilizer (L3170) and ankle-foot orthosis (L1971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed supply codes cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. The date of service on the claim is not the ship date or delivery date. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the heel stabilizer and ankle-foot orthosis provided on April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220), limited (problem-focused) oral evaluation (D0140) and porcelain/ceramic crown (D2740) provided on January 13, 2021.

You asked the Plan to pay for the dental services. You say that you did not realize that your optional supplemental benefit terminated at the end of the last plan year. You re-enrolled after you realized and request the Plan cover these services. The Plan denied your request. The Plan says at the time of service, you were only enrolled in the mandatory supplemental benefit. The Plan states that the Annual Notice of Changes indicated that the dental plan you were enrolled in would not be available in 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 requested items or services are not among those covered under the benefit you were enrolled in on the date in question. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220), limited (problem-focused) oral evaluation (D0140) and porcelain/ceramic crown (D2740) provided on January 13, 2021.

Your complaint about possible confusion or missing information regarding your optional dental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 5,10-methylenetetrahydrofolate reductase gene analysis (81291) provided on November 11, 2020.
You asked the Plan to pay for the 5,10-methylenetetrahydrofolate reductase gene analysis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is a non-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 5,10-methylenetetrahydrofolate reductase gene analysis have not been met. Specifically, this testing is considered investigational and not a covered benefit. Therefore, we decided that the Plan does not have to pay for 5,10-methylenetetrahydrofolate reductase gene analysis (81291) provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle or scooter (K0800).

You asked the Plan to pre-approve a scooter. You say that the requested scooter will fit in the enrollee's home.
The Plan denied your request. The Plan says the requested scooter is not appropriate for the enrollee's living
space.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 scooter. Our reviewer says that the
requested item is not medically necessary. Our physician reviewer found that the enrollee has a mobility
limitation that significantly impairs ability to participate in one or more mobility-related activities of daily
living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the
home. The mobility limitation is unable to be helped by a cane, walker or manual wheelchair due to a torn left
shoulder ligament, arthritis of the hand, and shortness of breath, cardiac and pulmonary issues. The
documentation does not reveal that the requested device will fit adequately in the enrollee's home for
maneuvering and participating effectively in MRADLs in the home. The enrollee is noted to live in a mobile
home. The entrance to the bathroom width is noted 25" and the entrance to the bedroom is 25" wide. The
Victory 9 3-wheel specifications indicate that the overall width of the base is 27.25"; therefore, the
documentation does not support that there is adequate maneuvering space in the home for MRADL
participation for the requested 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 a scooter have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Group 1 power operated vehicle or scooter (K0800).