Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on January 4, 2021 by an out of network provider.

You asked the Plan to pay for psychotherapy. You say that the Plan is required to pay at least the original Medicare rate. The Plan denied your request. The Plan says you did not request prior authorization for the out of network services.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 4, 2021 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) scan provided to the
enrollee on March 2, 2021.

You asked the Plan to pay for the PET scan. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate diagnosis and service codes that report the service billed to
the highest degree of specificity. The claim itself was billed with a diagnosis code of "C14.0 defined as
Malignant neoplasm of pharynx, unspecified." However, the medical records provided indicate there was a
more specific part of the body that was the area of concern.

In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific
codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body
required imaging, the claim should have reflected that with the appropriate codes being billed and submission
of the appropriate medical record documentation. Medicare rules for coverage of this claim as billed have not
been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET)
scan provided to the enrollee on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro powered upper limb orthosis for the enrollee.You asked the Plan to pre-approve the orthosis. You say that this is medically necessary.The Plan denied your request. The Plan says there are no well-designed placebo-controlled studies or studies of adequate sample size that have determined that this equipment is necessary for the treatment of those with upper extremity weakness.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 orthosis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approve the MyoPro powered upper limb orthosis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral knee injections.
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches,
including imaging guidance, when performed (64454). You say that the enrollee needs the injections for pain
relief. The Plan denied your request. The Plan says peripheral genicular nerve blocks are not covered for
chronic pain.
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 injection(s), anesthetic agent(s) and/or
steroid; genicular nerve branches, including imaging guidance, when performed (64454). Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the use of genicular nerve blocks is experimental/investigational for knee pain after total knee
arthroplasty. Therefore, the request is deemed not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches,
including imaging guidance, when performed (64454) have not been met. Therefore, we decided that the Plan
does not have to pre-approve bilateral knee injections.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided on December 5, 2020.You asked the Plan to pay for the ambulance transport services. You say that you were unable to be transported by any other way due to your health condition.The Plan denied your request. The Plan says the services should be processed by Original Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 
You were under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for ambulance transport services provided on December 5, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the carotid sinus Barostim device.
You asked the Plan to pre-approve the carotid sinus Barostim device. The Plan denied your request. The Plan says that this is an experimental procedure.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 carotid sinus Barostim device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that Barostim Neo carotid stimulation device implantation is a newer FDA approved therapy which has randomized data to support its use in improving quality of life and 6-minute walk capacity in patients who have persistent and significant symptoms of CHF, despite full guideline directed medical therapy. The enrollee in question is on full guideline directed CHF medications, but has been admitted recently for decompensated CHF. He has persistent NYHA Class III heart failure symptoms with dyspnea after 100 feet of walking. As the enrollee has significant ongoing symptoms and is already on full guideline-directed medical therapy, he would meet the FDA indications for the Barostim Neo device to improve his persistent dyspnea symptoms and quality of life. Therefore, this would not be considered experimental therapy in this specific clinical situation. 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 carotid sinus Barostim device have been met. Therefore, we decided that the Plan has to pre-approve the carotid sinus Barostim device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections with moderate sedation 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 this 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the ASA Committee on Pain Medicine specially states that Monitored Anesthesia Care is not needed for
diagnostic medial branch blocks. Additionally, the enrollee only received 50% pain relief from the first set of
diagnostic blocks. The criteria are not met.
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 facet joint injections with moderate sedation for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Iluvien for the enrollee.
You asked the Plan to pre-approve Iluvien. You say that this drug 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 Iluvien. The medical records show the enrollee is a 63-year-old woman with a diagnosis of Type 2 diabetes mellitus with proliferative diabetic retinopathy with bilateral macular edema. The case file contains an Eye Institute Visit Note dated February 24, 2021. The enrollee had bilateral proliferative diabetic retinopathy with persistent macular edema. The case file contains additional information on a Medication Intake Team form. Our Medical Director has concluded that the Plan is correct in this case. Iluvien is indicated for the treatment of diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure. The clinical documentation in the case file is insufficient to demonstrate that the FDA indication for the drug was satisfied in this case. A response form that contains additional information indicates that the enrollee had a clinically significant rise in intraocular pressure with previous treatment with a course of corticosteroids. Consequently, the documentation in the case file does not support that the drug was used for an FDA-approved medically accepted indication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Iluvien have not been met. Therefore, we decided that the Plan does not have to pre-approve Iluvien for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 5, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on February 3, 2021.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 tests that include more than 5 viral pathogens are non-covered.We looked at the file and Medicare rules. The file shows that the testing was for more than 5 viral pathogens. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from November 1, 2020, to November 13, 2020.You asked the Plan to waive the coinsurance for dialysis. You say that you disagree with how the claims were processed.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for dialysis for services to treat kidney disease. You received dialysis from November 1, 2020, to November 13, 2020, for a total of 13 visits. Therefore, you are responsible to pay $1,391.25, which is less than the 20% coinsurance amount for dialysis. You have been asked to pay the total coinsurance amount of $1,391.25 for dialysis. Dialysis falls within the services to treat kidney disease 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 dialysis provided from November 1, 2020, to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 25, 2020 by an out of network (OON) provider.You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.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 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 the subsequent nursing facility care provided on November 25, 2020 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.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 23, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided June 5, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 G0483 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on February 4, 2021.
You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that the physician ordered this device. The Plan denied your request. The Plan says this device and supplies are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home or in any setting.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) 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 the pneumatic compression device and appliances provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 17, 2020 by an out of network (OON) provider.You asked the Plan to pay for lab test. You say that this testing is a Medicare covered benefit and should be paid by the Plan.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on December 17, 2020 by an out of network (OON) provider.