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

We decided that the Plan does not have to pre-approve a ventilator.
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a ventilator is covered for the criteria established in the applicable LCD. 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 ventilator.
Our reviewer says that the requested ventilator is not medically reasonable and necessary. Our physician reviewer found that the enrollee is an 81-year-old female with COPD and acute on chronic respiratory failure with hypercapnia. A portable home ventilator unit was requested. A recent hospitalization showed that BiPAP normalized her respiratory acidosis along with supplemental oxygen administration. Therefore, as there was objective evidence of tolerance and appropriateness of BiPAP and insufficient support for a ventilator, this request for such will be considered not 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 22, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

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.

The Plan must follow Medicare rules. Medicare rules say that facet joint injections are 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 not medically necessary. Our physician reviewer found the enrollee has a history of back pain and had facet joint blocks in December of 2020 and April of 2021 with long lasting pain relief. There is no documentation to support why she is not a candidate for radiofrequency ablation as definitive management of her symptoms. The criteria for facet injections are not met and the services are not 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 facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compresssion device (E0652, E0667) 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 there has been no documented trial of conservative therapy demonstrating failed response to 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prescribing provider has stated that the segmented pump is preferred and there is no indication that the enrollee has trialed a standard pump. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compresssion device (E0652, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11043) rendered by the OON provider on March 30, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the debridement services (11043) rendered by the OON provider on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided from March 19, 2021 to March 29, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says payment is not allowed for services provided by a chiropractor other than manipulation of the spine. The Plan attempted to get corrected claim from the provider but did not receive any response.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for out of network chiropractic care provided from March 19, 2021 to March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis you received on March 30, 2021.
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that you were not aware that you had to pay coinsurance for this item. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for prosthetic devices and supplies (including braces).
You have been asked to pay 20% coinsurance for the lumbar-sacral orthosis. The lumbar-sacral orthosis falls within the prosthetic devices and supplies (including braces) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis you received on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth #16 for the enrollee.

You asked the Plan to pre-approve surgical removal of erupted tooth #16 for the enrollee. You say that these dental services are medically necessary. The Plan denied your request. The Plan says the requested dental services are not covered. Maximus overturned the Plans denial. The Plan requested a reopen and states that Maximus determined the Plan had to pre-approve the surgical extraction of an erupted tooth (D7210) for tooth # 16 when the predetermination request was for tooth #15. 2. The Maximus physician reviewer incorrectly stated that tooth #16 appeared to be in the position of tooth #15. That statement is factually incorrect. The Plan submitted imaging which confirms tooth #16, while tipped slightly in the direction of the missing tooth #15, is still clearly separated from tooth #14 by the space where tooth #15 previously occupied and clearly shows 15 is missing. The Plan states in order to consider application of allowed benefits in this case, the provider must submit a claim on the enrollee's behalf that is accurate and includes the correct tooth number (16).

The Plan is correct in this case. 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 incorrect service was requested and needs to be corrected by the provider. Therefore, we decided that the Plan does not have to pre-approve surgical removal of erupted tooth #16 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830). You say that the enrollee's excess skin on her abdomen affects her activities of daily living including personal care, hygiene and dressing. The Plan denied your request. The Plan says they do not see that the enrollee has problems with extra skin that had not gotten better with non-surgery treatment, or extra skin that hangs below the pubis.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830). Our reviewer says that the surgery is not medically necessary. Our reviewer found the available documentation does not support that the proposed panniculectomy is medically necessary to treat complicating factors of the excess abdominal skin.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (15830) have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.
You asked the Plan to pay for the laboratory services. You say that the GW modifier was used to indicate the patient is in hospice. You say that the charges are for coronavirus testing and not related to hospice care. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), crown (D2740), core buildup, including any pins when required (D2950), and sales tax (D9985) provided from March 17, 2021, to April 8, 2021.

You asked the Plan to pay for the preventive procedure, crown, core buildup, and sales tax. You say that you have a $2,000 dental allowance and do not want to pay anything for this bill. The Plan denied your request. The Plan says these services are not covered under your 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. 

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 preventive procedure (D1999), crown (D2740), core buildup, including any pins when required (D2950), and sales tax (D9985) provided from March 17, 2021, to April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a crown for tooth number 19.
You asked the Plan to provide coverage for a crown for tooth number 19. You say that these dental services
are medically necessary. The Plan denied your request. The Plan says the criteria needed for coverage of this
service are not met. Maximus overturned the Plans denial stating the treatment was necessary. The Plan
requested a reopen and stated that Maximus did not follow the Plans benefit criteria. The Plan says that the
dental contract criteria shows authorizations for crowns will not be met if the tooth has advanced periodontal
disease. The Plan states our medical review confirms this condition is present.
The Plan is correct in this case. Medicare does not cover dental services. 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 condition of the tooth being treated did not meet the
Plans criteria for coverage for a crown due to the confirmed periodontal disease. Therefore, we decided that the
Plan does not have to provide coverage for a crown for tooth number 19.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional HH skilled nursing visits.
You asked the Plan to pre-approve the additional HH skilled nursing visits. You say that you need these services for removing and inserting a new supra pubic catheter once a month because you cannot perform this function by yourself. The Plan denied your request. The Plan says you no longer require skilled nursing management.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 additional HH skilled nursing visits. Our reviewer says that the additional HH skilled nursing visits are not medically reasonable and necessary. Our physician reviewer found your homebound status is unclear. Our reviewer also found that your catheter appears to have no acute issues (e.g. new, infected, hematuria, clogging). 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 additional HH skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional HH skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Mohs micrographic technique provided on March 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for Mohs micrographic technique. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 Mohs micrographic technique provided on March 15, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper eyelid surgery, rhytidectomy, and right knee liposuction.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these procedures 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have had previous bilateral upper and lower blepharoplasty in 2019 and noticed that your left eye has been drooping more since the surgery. Fifty-nine percent improvement was reported with taped lid on the right, and 20% improvement was reported with taped lid on the left. On 5/14/21, an MRD of approximately 3.5 mm was documented. Formal visual field testing was not documented. The documentation supports that the requested rhytidectomy and liposuction is cosmetic in nature. The documentation is insufficient to demonstrate functional impairment. The documentation in the case file, which includes photographs, is insufficient to demonstrate that the coverage criteria for revision of bilateral upper blepharoplasty have been met 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve upper eyelid surgery, rhytidectomy, and right knee liposuction.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health services provided to the enrollee on March 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this is an out of network claim submitted for a clinical psychologist without prior authorization.
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 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 out of network outpatient mental health services provided to the enrollee on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who meet coverage criteria. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
February 27, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the
enrollee on February 27, 2020.