Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. There was no MRI provided to determine the presence or severity of lumbar spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. Specifically, there is no discussion indicating that a DEXA scan has demonstrated no significant osteoporosis in your case. (Within the evaluation, it was noted that you have osteoporosis.) This would likely represent a contraindication to this device. Superion indirect lumbar decompression would not be considered the standard of care for your medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of your medical condition. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 8, 2020, through October 14, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this is not durable medical equipment and was not delivered to the member's home. The Plan denied your request. The Plan says this code is not recognized for non-participating providers.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 8, 2020, through October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.

You asked the Plan to pay for evaluation visit. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for evaluation visit was not filed until August 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge.
You asked the Plan to pre-approve positioning cushion/pillow/wedge. You say that this is necessary for your back pain and sleeping issues. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Hyaluronan or derivative, gel-one, for intra-articular injection, per dose (J7326). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says that the request does not meet the Plan's Part B step therapy criteria for the requested drug.
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. The Plan failed to substantiate their decision with medical records or medical notes. Therefore, we decided that the Plan has to pre-approve Gel-One (J7326).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (S9122).

You asked the Plan to pay for home health aide services. You say that this should be covered. 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.

We find that CPT code S9122 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home health aide services have not been met.
Therefore, we decided that the Plan does not have to pay for home health aide services (S9122).
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 enrollee needs to get attentive care to go home in the best condition. The Plan denied your request. The Plan says the enrollee does not need physician supervision 3 times per week, or require a multidisciplinary approach to daily therapy.
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 hospital for pneumonia and pulmonary embolism after recent hip fracture with surgical repair. His medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and occupational therapy, there is no documented need for intensive rehabilitation 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 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 photochromatic lens.
You asked the Plan to pre-approve the lens. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve a photochromatic lens.
Appeal type: Imaging
Decision: Favorable

We have decided to dismiss the Plan's request to reopen the case because it does not meet Medicare rules for a reopening. The Plan submitted their own physician review of this case in which they disagree with our decision. Our Medical Director looked at the case file and the reopen request. At issue is coverage for an MRI of the cervical spine. The Maximus Physician Reviewer determined that MRI was appropriate. The Plan states that there is no documentation in the case file of failed therapy. The medical records show
the exam demonstrated abnormal strength in the right arm. The diagnosis was cervical radiculopathy. Methocarbamol and ibuprofen were prescribed. The x-ray showed moderate degenerative changes and an MRI was ordered. Our Medical Director has concluded this appears to be a difference of opinion among medical experts. When making medical necessity determinations, Maximus physician reviewers consider many factors including peer reviewed literature, practice guidelines, and current standards of care. Determinations of medical necessity are tailored to the individual patient and their unique clinical scenario. In this case, a Maximus Physician Reviewer, with appropriate expertise and qualifications, rendered an unbiased and well-considered opinion. The medical review was appropriate and well-supported by documentation in the case file. While an MRI is often performed for neck pain that did not improved with conservative measures, this imaging study may also be indicated when neck pain is accompanied by numbness or weakness. Thoughtful, qualified experts can and often do, disagree about interpretations of case file evidence and its application to coverage determinations. The fact that the health plan disagrees with our expert's opinion is not in itself sufficient grounds for reversing the determination in this case.
We find no evidence of error in this case and we are therefore dismissing the request to reopen. Our decision remains that the Plan has to provide coverage for magnetic resonance imaging (MRI) of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stairway elevator/chair lift.
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stairway elevator/chair lift.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
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 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 acute on chronic respiratory failure. The enrollee's medical problems 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic surgery consultation (99214) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON orthopedic surgery consultation. You say that you are not fond of the in-network doctors. The Plan denied your request. The Plan says these services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an orthopedic surgery consultation (99214) 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 long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request at issue is coverage for LTACH services. The MAXIMUS Physician Reviewer determined that the medical records indicate that the enrollee has active open wounds on the lower extremities that require aggressive wound care and expertise management. This would need to be done at a LTACH where a physician can assess the wounds on a daily basis and manage the active infection. The Plan argues that the enrollee's ongoing wound management was not complex and did not require daily physician level management. The medical records show the enrollee is a 62-year-old man with bilateral posterior lower extremity wounds. The enrollee was diagnosed with sepsis secondary to cellulitis with necrotizing wounds. A wound vacuum was placed on the left lower extremity. Three weeks of IV antibiotics were planned. Lab work was to be followed once weekly. The enrollee was working with physical therapy and was getting into a chair daily. Our Medical Director has concluded the Plan is correct in this case. The documentation did not support that the enrollee in this case required services at the LTACH that were not available at the acute care hospital where he was receiving care. There were no required medical services identified that were available at the LTACH, that were not available at the health care setting that was being offered by the health plan. The requested LTACH services were not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at that time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care.

You asked the Plan to waive the copayment for SNF care. You say that you do not feel you should be responsible for this big of a copay. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 copayment per day for days 1 to 20 of a benefit period, a $60 copayment per day for days 21 to 44 of a benefit period, and a $0 copayment per day for days 45 to 100 of a benefit period for Skilled Nursing Facility (SNF) care. These SNF stays lasted a total of 44 days, however the Plan has only asked you to pay $1,560 total, which is less than the applicable copayment amount for 44 SNF days.

You have been asked to pay a $20 copayment per day for days 1 to 20 of a benefit period, a $60 copayment per day for days 21 to 44 of a benefit period, and a $0 copayment per day for days 45 to 100 of a benefit period for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on October 8, 2020, by an OON
provider.
You asked the Plan to pay for x-ray services. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for x-ray services provided on October 8, 2020, by an
OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion interspinous spacer device (22869).
You asked the Plan to pre-approve the Vertiflex Superion device. You say that included with this letter is the clinical documentation which supports these clinical findings and medical necessity for the procedure. You have treated many patients with this procedure who have had positive results. The Plan denied your request. The Plan says Vertiflex does not meet the accepted standards of medical practice. Vertiflex is investigational and experimental, and the enrollee is not receiving this device as part of a Medicare covered clinical trial.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion interspinous spacer device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient Podiatry office visits (99213,
99202) provided from April 20, 2020, to September 21, 2020.
You asked the Plan to waive the copayment for the office visits. You say that every appointment you had with
this podiatrist was a routine office visit for trimming toenails and filing callouses. You were told by a plan rep
that the podiatrist submitted claims for other services not considered routine. The Plan denied your request. The
Plan says the claim was processed, and the correct copayments were applied per the Evidence of Coverage.
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 $35.00
copay for each covered specialist office visit.
You have been asked to pay copay ($105.00 ($35.00 x 3 = $105). The office visits fall within the
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the outpatient Podiatry office visits (99213, 99202) provided from April 20, 2020,
to September 21, 2020.