Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 8, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on July 8, 2019.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a stress test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a same or similar study was recently approved. 
 
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 has not substantiated their denial. The case file indicates that the plan 
had medical records available for their review and denial. None of these records were provided to MAXIMUS 
for review. Therefore, we decided that the Plan has to pre-approve a stress test for the enrollee.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. 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 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 physical therapy 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 the requested therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition with 
minimal objective functional improvement and persistent pain. The documentation does not support that they 
require the unique skills of a professional therapist to safely and effectively provide treatment for the pelvic 
pain condition. Services do not need to safely and effectively be performed only by a therapist, or under the 
supervision of a therapist. The enrollee has had extensive therapy and was trained in a home exercise program. 
The requested services are not part of a maintenance program and the specialized skill, knowledge and 
judgment of a qualified therapist is not 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydrocodone - Ibuprofen 7.5-200. 
 
You asked the Plan to pre-approve Hydrocodone - Ibuprofen 7.5-200. You say that the requested medication is 
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not 
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone - Ibuprofen 
7.5-200.  
 
Benefits for Hydrocodone - Ibuprofen 7.5-200 may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
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 services are medically necessary. The Plan denied your request. The Plan says there is no clinical advantage of LTACH services at this time.
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 patient does not require any services at the proposed LTACH that are not already available at the current facility. Continued care at the current facility is recommended. This request for LTACH services will be considered not medically necessary at this time. A lower level of care can be considered when acute care is complete. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a nuclear stress test.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a nuclear stress test is covered when specific criteria are met. 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 services are medically necessary. Our physician reviewer found the enrollee has a history of persistent atrial fibrillation, diabetes, hypertension, hyperlipidemia, mild mitral stenosis, aortic valve sclerosis, prior smoking, obstructive sleep apnea, congestive heart failure with preserved ejection fraction and non-sustained ventricular tachycardia on ambulatory monitoring. An echocardiogram on July 12, 2020 reported normal wall motion and ejection fraction. There is no documentation of chest discomfort. The enrollee has multiple coronary risk factors, congestive heart failure, and newly recognized ventricular tachycardia that may be is chemically mediated. The requested nuclear stress test is the standard of care, meets the criteria for coverage, and is medically necessary at this 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a nuclear stress test.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network radiation therapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service can be safely provided in-network by participating providers.
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 a referral for out-of-network radiation therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 4, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this should be coded with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that continuity of care is vital for the best outcome. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TuoJeo Solostar.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve TuoJeo Solostar.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are 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 bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has an injured back. Bone marrow aspiration remains experimental. 
More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the 
requested 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
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 the services are medically necessary. The Plan denied your request. The Plan says the services are 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 LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with knee pain, positive blood cultures, and positive urine culture. She currently needs one to two weeks of additional antibiotics, total parenteral nutrition, and basic wound care. She does not require services at the LTACH that are not already available at the current facility. There are no services available at the LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH services are therefore not reasonable or medically 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2750) 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 D2740 and D2750 are allowed once per tooth per sixty months, per patient.
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. The Plan covers crowns once every sixty months. The case file appears to show that D2750 was only requested in case D2740 was not approved. The file shows that D2740 was approved, which means that that crowns cannot be covered again for sixty months/five years. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are available contracted providers in the same orthopedic practice.
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 a referral to an out-of-network orthopedic surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Celebrex capsules.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Celebrex capsules.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical equipment provider.
You asked the Plan to pre-approve these services. You say that you have chronic obstructive pulmonary disease (COPD) and your doctor prescribed the equipment. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network durable medical equipment provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Promethazine.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that crutch substitutes are denied as not medically necessary. We looked at the file and Medicare rules. The item at issue is a crutch substitute described by procedure code E0118. This item is denied by Medicare for all indications. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth number 31 (D2740) and core buildups for teeth numbers 21 and 31.
You asked the Plan to pre-approve dental crown and core buildups. You say that you have pain in your gums and difficulty eating but cannot afford these services. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee has exhausted the benefit for dental crowns and core buildups are not covered by the Plan.
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. You received a crown on June 22, 2020, therefore the Plan's benefit of one dental crown per calendar year is exhausted at this time. Furthermore, the requested core buildups are not covered by the Plan's dental benefits. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth number 31 (D2740) and core buildups for teeth numbers 21 and 31.