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

We decided that the Plan does not have to pre-approve a manual wheelchair (K0001).

You asked the Plan to pre-approve a manual wheelchair (K0001). You say that the requested manual wheelchair (K0001) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested manual wheelchair (K0001).

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 a manual wheelchair (K0001). Our reviewer says that the enrollee does not meet criteria for the requested manual wheelchair (K0001). Our physician reviewer found the enrollee has Alzheimer's dementia and is having increasing gait instability. The wheelchair is requested to assist the husband in transporting the enrollee. The provided medical records are insufficient to establish whether the enumerated criteria of the coverage rule are 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 a manual wheelchair (K0001) have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (K0001).
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for surgical repair of a hip fracture after a fall. She is now medically stable with 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need beyond the last covered date. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a PET scan provided to the enrollee on January 4, 2021.

You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the history dictated in the PET/CT of 1/4/21 indicates left breast malignancy with axillary involvement. The diagnostic code listed was C50.912. While the enrollee appears to qualify for PET/CT the correct code for CPT 78815 should have been C50.612. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pay for a PET scan provided to the enrollee on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on February 9, 2021.
You asked the Plan to pay for the dental services. You say that dental oral examination and dental x-rays are covered by your plan. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either.
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. The record shows that you have not purchased the optional supplemental dental rider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray (D0220) provided on February 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.
You asked the Plan to pre-approve the inpatient hospital services. You say that the enrollee has a history of seizures and tremors. You say that the enrollee's doctor is requesting the enrollee spend one night after surgery for monitoring, due to his other health issues. The Plan denied your request. The Plan says the guidelines for coverage of inpatient hospital care have not been met. The Plan says that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan says that there is no documentation to support the expectation that the enrollee will require a greater than a 2 midnight stay.
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 the inpatient hospital services. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee has right knee pain related to severe osteoarthritis and presented to the hospital for an elective right total knee arthroplasty. The provided records did not describe a significant enough indication for inpatient services around this elective surgery. Observation status or a re-evaluation for inpatient status could be considered during or following surgery based on an updated clinically status. There was no expectation that there would likely be a complex surgery or prolonged recovery. There was no evidence to suggest this enrollee would require hospitalization that would likely cross 2 midnights. 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device for the enrollee.
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that this device is medically necessary for the enrollee. 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 a MyoPro Motion G Orthotic device. The Maximus Physician Reviewer determined that the request for MyoPro Motion G Orthotic device was made to improve overall right arm function. The Plan argues that the reviewer did not take into account that the enrollee's actual medical records from the provider who ordered this device are not included in the records sent for review. The Plan notes the ordering provider has not personally examined this enrollee nor has he documented the specific treatments the enrollee has tried and failed. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the MyoPro Motion G Orthotic device was medically reasonable and necessary. The clinical documentation by the ordering physician does not support that the requested orthotic device is an accepted standard of medical practice that meets but does not exceed the enrollee's medical need and does not indicate that the device is at least as beneficial as existing and available medically appropriate alternatives. Medicare 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 a MyoPro Motion G Orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with a single power option (K0835) with a power seat elevation system (E2300) and related electronic connection (E2310), with other accessories (K0108).
You asked the Plan to pre-approve the Group 2 PWC with single power option and the power seat elevation system. You say that this PWC is medically necessary and should be covered. The Plan denied your request. The Plan says Medicare does not cover power seat elevation. In addition, if a Group 2 PWC is requested with a single power option, and that power option is solely a power seat elevation system, the PWC will be denied.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. When the single power option code is requested for a Group 2 PWC, it cannot be covered.
Based on this information, the requested PWC with single power option and all requested accessories are noncovered. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with a single power option (K0835) with a power seat elevation system (E2300) and related electronic connection (E2310), with other accessories (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute lower leg platform (E0118).
You asked the Plan to pre-approve crutch substitute lower leg platform. You say that your apartment is too
small for a wheelchair or walker, and you do not have enough strength to use a traditional walker. The Plan
denied your request. The Plan says this item 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 crutch substitute lower leg platform.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the documentation does not support that you can safely and effectively
use this device for ambulation. There is no objective neuromuscular evaluation or gait evaluation indicating
that you cannot meet your functional needs with a standard walker. This crutch substitute lower leg platform or
"roll about" is not proven to be the standard of care for your condition or proven to be safe and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of crutch substitute lower leg platform have not been met. Therefore, we decided
that the Plan does not have to pre-approve a crutch substitute lower leg platform (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal injection for the enrollee.
You asked the Plan to pre-approve this injection. You say that this injection is medically necessary., The Plan denied your request. The Plan says Medicare coverage criteria are not met
The Plan must follow Medicare rules. Medicare has specific rules for this type of injection. 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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical records provided show the enrollee's symptoms can be due to several different pain generators. Our physician reviewer says that at this point, the request is 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 this injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the requested items are a necessity
for your care. The Plan denied your request. The Plan says rules for durable medical equipment have not been
met.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight (8) PT visits.
You asked the Plan to pre-approve an additional eight (8) PT visits. The Plan denied your request. The Plan says eight (8) physical therapy visits does not meet medical necessity criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional eight (8) PT visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is
not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You can transition to an independent home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 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 an additional eight (8) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) PT visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0428-GY, A0425-GY) provided on February 15, 2021.
You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid with the modifiers billed.
The Plan must follow Medicare rules. Medicare rules say that modifier -GY indicates that the billed code is an item or service statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted with this modifier are non-covered and will be denied.
We looked at the file and Medicare rules. The services at issue were billed with modifier -GY. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428-GY, A0425-GY) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the item is necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) received January 6, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you have periodontal disease, and the requested service was necessary. The Plan denied your request. The Plan says the requested 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 pay for the comprehensive periodontal evaluation (D0180) received January 6, 2021.