Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses (V2020, V2200) purchased on January 7, 2021.You asked the Plan to pay for the eyeglasses. You say that the lenses provided on these eyeglasses were not right and did not work for you, so you had to go back on January 26, 2021, to have them replaced. You also upgraded the lenses at that time. The Plan denied your request. The Plan says that you have a $125 allowance for lenses and frames, and this allowance has been exceeded, so the remaining cost of the eyewear is your responsibility.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan can cover one pair of frames and lenses every 24 months. Your contract with the Plan 
clearly states that you must pay $0 for vision care. The contract does not say in clear and accurate terms whether or not there is an allowance or maximum dollar amount for any specific vision care services. We looked at the file and the Plan's rules. You have been asked to pay more than $0 for the eyeglasses in question. Therefore, we decided that the Plan has to pay the full cost of the eyeglasses (V2020, V2200) purchased on January 7, 2021.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95938, the nerve conduction studies coded 95910, the needle electromyography services coded 95886, and the sacral nerve stimulation test lead coded A4290 provided on November 5, 2020.

You asked the Plan to pay for the short-latency somatosensory evoked potential study, the nerve conduction studies, the needle electromyography services, and the sacral nerve stimulation test lead. 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 CPT code.

We find that CPT codes 95938, 95910, 95886, A4290 are not supported in the medical record. Specifically, the billed place of service for these services was 15 (mobile unit). The billed place of service 15 is not supported.

The documentation submitted indicates that the enrollee received services in a facility setting. Based on this
information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential
study, the nerve conduction studies, the needle electromyography services, and the sacral nerve stimulation test
lead have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency
somatosensory evoked potential study coded 95938, the nerve conduction studies coded 95910, the needle
electromyography services coded 95886, and the sacral nerve stimulation test lead coded A4290 provided on
November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the healthcare setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coflex device surgery for the enrollee.You asked the Plan to pre-approve these services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the Coflex is investigational and experimental.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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Coflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Coflex device surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the garment defibrillator (K0606) provided on December 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for automatic external defibrillator. You say that you're requesting the plan to reconsider payment based on medical necessity and the supporting documentation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the garment defibrillator (K0606) provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIluvien for the enrollee.You asked the Plan to pre-approveIluvien. 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. The Plan states Iluvien is FDA-approved and supported 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 medical records show the enrollee is a 62-year-old woman with a diagnosis of Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema in the left eye. The case file contains an Ophthalmology Office Visit note dated January 26, 2021. The enrollee had persistent proliferative diabetic retinopathy.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-approveIluvien for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Airos 8 brand pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that you are the only provider who supplies this device. The Plan denied your request. The Plan says there are network providers available.
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 the documentation does not reveal objective physical exam findings of lymphedema of the chest, trunk, or abdomen or unique characteristics that would indicate the segmented pump over a standard pump. The documentation does not reveal objective documentation of a four-week trial and failure of a standard pump with detailed measurements. The documentation does not reveal extenuating factors that require this enrollee to go out-of-network to get this specific brand. 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 Airos 8 brand pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0648) provided October 23, 2020.
You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 relevant medical records which support medical necessity for the supplies provided in this case. The documentation does not show that the provider discussed the need for this specific item with the enrollee. 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 an orthosis (L0648) provided October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on January 15, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was billed with an inappropriate diagnosis code. 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 positron emission tomography (PET) scan rendered on January 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional PT visits.
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says four (4) additional PT visits are not medically necessary because you manage your symptoms on your own.
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 four (4) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have plateaued with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's 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 four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 9, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation did not contain a signed physician order.

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. The records provided do not contain documentation of the ordering physician's intent that the tests 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 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 5, 2020.

You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with the correct code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met.

Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve these services. You say that you prefer a transfer.The Plan denied your request. The Plan says that there is no medical need to be transferred.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 inpatient hospital services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 15, 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 December 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual pelvic exam received on January 13, 2021.You asked the Plan to pay for the annual pelvic exam. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received are not a covered benefit.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 pay for the annual pelvic exam. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you are postmenopausal G2P2 with multiple medical problems but no history of abnormal pap smears. You underwent an annual pelvic exam on January 8, 2020, appropriately, no pap smear was sent as you were over 65 years of age. You then returned for another gynecologic annual pelvic exam on January 13, 2021, again, appropriately, a pap smear was not sent but a pelvic exam was performed. However, at both visits,you were evaluated for atrophic vaginitis which is part of a pelvic examination. You met criteria for the pelvic exam received on January 13, 2021.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 annual pelvic exam have been met.Therefore, we decided that the Plan has to pay for the annual pelvic exam received on January 13, 2021.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 pay for office visit services (CPT 99213) services provided to the enrollee on November 14, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says pre/post-operative care payment is included in the allowance for the surgery/procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99213 is "Evaluation and management of an established patient in an office or outpatient location for 15 minutes." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not include an evaluation and management visit to support the use of CPT 99213. Therefore, this service cannot be confirmed as performed.
We looked at this coder'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 pay for office visit services (CPT 99213) services provided to the enrollee on November 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided from July 1, 2020, to July 2, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes remain 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. The file shows that the enrollee received at home physical therapy services by an occupational therapist. We find that the billed CPT codes are not supported in the medical record. Procedures must be reported with the most comprehensive CPT code that describes the services performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided from July 1, 2020, to July 2, 2020.