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

We decided that the Plan does not have to pre-approve the transcatheter implantation of a wireless pulmonary artery pressure sensor, CardioMEMS device (33289).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary for the enrollee.

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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was hospitalized with acute-on-chronic congestive heart failure. The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical research is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee in this case.

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the transcatheter implantation of a wireless pulmonary artery pressure sensor, CardioMEMS device (33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided.
You asked the Plan to pre-approve foot orthotics. You say that this is not experimental and you have been prescribed orthotics over the last dozen years. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a HHA.
You asked the Plan to pre-approve the HHA. You say that the enrollee would benefit from receiving HHA services 6 hours a day for 6 days per week. You also say that you recommend the enrollee receive these services for at least 1 year. The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a HHA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).

You asked the Plan to pre-approve a shower chair. You say that the enrollee requires a shower chair. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the enrollee requires the CGM. The Plan denied your request. The Plan says the enrollee only utilizes insulin twice a day, the requirement is three or more.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex spacer device is experimental. More research is needed to show safety and efficacy of the spacer. 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 spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-invasive ventilator.
You asked the Plan to pre-approve the non-invasive ventilator. You say that you would like reconsideration because this equipment is necessary for you to be able to continue treatment. The Plan denied your request. The Plan says the records provided demonstrate that you are not compliant with treatment.
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 non-invasive ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was insufficient supportive documentation that you require a mechanical ventilation device as current oxygen and BiPAP appeared to be providing sufficient support for you. 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 non-invasive ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-invasive ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pain Management Injection treatment (CPT 64633 and 64634 ) for the enrollee.
You asked the Plan to pre-approve Pain Management Injection treatment (CPT 64633 and 64634). You say that this treatment 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 coverage criteria 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 Pain Management Injection (CPT 64633 and 64634). Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the medical records show the enrollee did not achieve 80% pain relief as required by the LCD. Therefore, 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 Pain Management Injection (CPT 64633 and 64634) have not been met. Therefore, we decided that the Plan does not have to pre-approve Pain Management Injection treatment (CPT 64633 and 64634 ) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for atrial fibrillation, coronary artery disease, mitral valve regurgitation and pneumonia. Cardiac surgery was performed. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the enrollee requires the device for the more sophisticated readings. The Plan denied your request. The Plan says the enrollee is not using insulin and therefore does not qualify.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the are no identifiable skilled nursing or therapy needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of inpatient skilled nursing facility care.

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
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee
has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled
therapy services on a daily basis. She is medically stable and can receive further rehabilitation services and
daily IV antibiotics at a lower level of care. Although further rehabilitation services would be appropriate to
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care
than a skilled nursing facility. Additionally, the enrollee is requiring IV antibiotics daily but this could be accomplished 
at a lower level of care with home health services. She does not have any complex wound care or
nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic
medical problems.

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 inpatient skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that this item should be covered. The Plan denied your request. The Plan says your coverage does not include maxillary partial dentures.
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 pre-approve the maxillary partial denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Capsular reconstruction procedure (29806).
You asked the Plan to pre-approve the surgical procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered investigational for the enrollee's condition and is not covered at this time.
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 surgical procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a recurrent rotator cuff tear. There is no clear documentation of shoulder instability. Capsular reconstruction is experimental for the treatment of rotator cuff tears without documented shoulder instability. More literature is needed to support the use of capsular reconstruction for rotator cuff tear. 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 surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Capsular reconstruction procedure (29806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (power scooter).
You asked the Plan to pre-approve power scooter. You say that you fall inside and outside of your home. The Plan denied your request. The Plan says you do not meet the Medicare criteria for this power scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that you do not meet the Medicare criteria for the requested power scooter. Our physician reviewer found you have a personal mobility deficit, but the documentation does not reveal that it impairs participation in mobility-related activities of daily living (MRADLs) in the home. Your mobility deficit can be helped by a walker in the home. The documentation does not show that you can safely maneuver the requested power scooter in your home as the home assessment notes the bedroom, hallways, bathroom, and entrance are not accessible to a power mobility device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (power scooter).
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.

You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial stating the PET scan was medically necessary. The Plan requested a reopen and provided additional information. The Plan says that this claim denied because the services billed were not reported with an appropriate diagnosis code and not because the services were not medically necessary. The rules say claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form-CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B). Medicare billing criteria were not met as the claim was not reported with the appropriate codes.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis codes. In this case, the claim cannot be paid as billed due to the omission of an appropriate diagnosis code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) scan provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response with no transport, provided on July 8, 2020, and billed under codes A0998, A0394, A0422, A0392 and A0382.
You asked the Plan to pay for this ambulance response. You say that this bill should be covered by the Plan. The Plan denied your request. The Plan says Medicare does not cover ambulance response with no transport. Maximus upheld and/or agreed with the Plan based on the Medicare rules. The Plan requested a reopen to include all of the codes that were billed for the transport.
Our decision remains unfavorable. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 8, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response with no transport, provided on July 8, 2020, and billed under codes A0998, A0394, A0422, A0392 and A0382.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services (97110, 97140, 97035) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the physical therapy services. You say that this enrollee does not want to attend any of the closer contracted providers and is adamant on coming to your facility for his physical therapy treatment. 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 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 the physical therapy services (97110, 97140, 97035) to be provided by an out of network (OON) provider.