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

We decided that the Plan does not have to pre-approve the combination air purifier and humidifier (E0555).
You asked the Plan to pre-approve the air purifier and humidifier. You say that this should not be denied
because your doctor told you to get an air purifier and humidifier because you have allergies that have come
back and you need this item to ease your allergies. The Plan denied your request. The Plan says this item is
considered environmental control equipment and is not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the combination air purifier and humidifier (E0555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous passive motion (CPM) exercise device
(E0936).
You asked the Plan to pre-approve CPM device. You say that you were confused when you were told this was
not covered from Medicare guidelines. You called Medicare and was told that the procedure fell into the
guidelines of joint surgery, which is covered 80%. The Plan denied your request. The Plan says a continuous
passive motion device is only covered for the knee after a total knee replacement.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have
received total knee replacement surgery.
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to
pre-approve continuous passive motion (CPM) exercise device (E0936).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an outpatient visit. You say that you would like to visit an out-of-network
provider. The Plan denied your request. The Plan says these services can be provided in-network. The Plan
says that there are three providers within 10 miles of the enrollee's address.
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
an outpatient visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified preventive procedure (D1999),
therapeutic parenteral drug (D9610), and two surgical placements of implant bodies: endosteal implants
(D6010 x2).
You asked the Plan to pre-approve the preventive procedure, therapeutic parenteral drug, and endosteal
implants. You say that you feel these services are medically necessary. The Plan denied your request. The Plan
says these services are not covered under your benefit package.
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 an
unspecified preventive procedure (D1999), therapeutic parenteral drug (D9610), and two surgical placements
of implant bodies: endosteal implants (D6010 x2).
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan does not have to waive the copayments charged to the enrollee for outpatient physical
therapy provided from March 12, 2020 to March 19, 2020.
You asked the Plan to waive these copayments. You say that you do not believe the enrollee is being charged
correctly. The Plan denied your request. The Plan says these copayments were charged based on the services
provided and the Plan contract agreement. Maximus partially overturned the Plans denial for incomplete claim
information. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the
Plan clearly says that enrollees must pay a $30 copayment for each outpatient rehabilitation visit. The enrollee
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayments charged to the enrollee for outpatient physical therapy provided from March 12,
2020 to March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve block (64494, 64493).
You asked the Plan to pre-approve nerve block. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are covered when specific criteria is 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 nerve block. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, since there is evidence of radiculopathy, the enrollee does not meet the criteria. The facet joint blocks are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve nerve block (64494, 64493).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT).
You asked the Plan to pre-approve PT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 PT. 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 in this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there are no indications that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed 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 PT have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT).
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal/contact guard assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auto bath lifter.
You asked the Plan to pre-approve an auto bath lifter. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an auto bath lifter.
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 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 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 review indicates that the enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. There is no documentation provided requiring admission to a LTACH. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care 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 and able to be furnished safely and effectively only on an inpatient 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery.
You asked the Plan to pre-approve back surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 back surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures for low back pain. A recent trial and failure of physical therapy is needed. Surgery is not needed 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 back surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient blepharoplasty.
You asked the Plan to pre-approve outpatient blepharoplasty. 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 follows Medicare rules. Medicare rules say that any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented patient complaints which justify functional surgery. 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 outpatient blepharoplasty. Our reviewer says that the services are not medically necessary. Our physician reviewer found the photograph submitted is insufficient to demonstrate the medical necessity of the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient blepharoplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514, 22515).
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 percutaneous vertebral augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for vertebral augmentation are not met. There is no documentation of conservative measures. The L1 vertebral fracture is of indeterminate age. More conservative measures are needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514, 22515).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography of the heart (75574).
You asked the Plan to pre-approve a CT angiography of the heart. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT angiography of the heart. Our reviewer says that the services are not medically necessary. Our physician reviewer found you are considered low risk for cardiac disease. Absent any positive findings on the stress nuclear medicine myocardial perfusion scan there is no medical necessity for a CT angiography of the coronary arteries documented within the submitted records. 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 CT angiography of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) angiography of the heart (75574).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, 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 PBRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted 
standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely 
offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77049). 
 
You asked the Plan to pre-approve an MRI of the breast. 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. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the breast. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found absent a documented genetic 
predisposition the enrollee does not qualify for breast MRI since her most recent mammogram was negative 
especially given the fatty nature of her breast parenchyma. As such there are very few limitations to 
conventional mammography as opposed to those enrollees with heterogeneously or extremely dense breast 
tissue. If there is a documentation of Lynch syndrome genetic predisposition in this particular enrollee upon 
genetic testing she would qualify for breast MRI on that basis but since no such testing result is available in the 
submitted records the medical necessity of breast MRI has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on January 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 has network providers 
available who can provide 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 medical services provided to you by an out-of-network provider on 
January 22, 2020.