Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a visual field assessment with real-time data analysis.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered screening.
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 record indicates that the enrollee has nonexudative macular degeneration. The record indicates that the requested service is being used as a recommended screening test for changes in vision. The record provided does not indicate that the requested service is more efficacious or safer for the enrollee than the standard of care that was advised. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.
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 visual field assessment with real-time data analysis
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 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 daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of inpatient psychiatric services from November 14, 2021, forward.

You asked the Plan to pre-approve additional days of inpatient psychiatric services from November 14, 2021, forward. You say that you feel that is not enough time for the enrollee to get the benefit of the medication that will stabilize the enrollee and make it save for them to come home. You also say that you need the enrollee to be stable when they are released.

The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 additional days of inpatient psychiatric services from November 14, 2021, forward. Our reviewer says that inpatient psychiatric care November 14, 2021, forward is not medically necessary. Our physician reviewer found the records provided did not indicate that it was expected the enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. The reviewer found that the enrollee was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. The reviewer also found that active treatment was not taking place after the dates in question. Therefore, the reviewer found that the requested inpatient psychiatric services beyond November 14, 2021, 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 additional days of inpatient psychiatric services from November 14, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve additional days of inpatient psychiatric services from November 14, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopic discectomy (62380).
You asked the Plan to pre-approve an endoscopic discectomy. You say that this surgery is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered investigational 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 an endoscopic discectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found endoscopic discectomy is experimental. More research is needed to show safety and efficacy of the procedure. Open surgery is the gold standard 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 an endoscopic discectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoscopic discectomy (62380).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the photodynamic therapy provided on May 10, 2021.
You asked the Plan to pay for the photodynamic therapy. You say that the previous procedure was a separate and distinct area. You say that notes are attached detailing each separate visit and this claim is payable. The Plan denied your request. The Plan says procedure code 96573 is included within the global surgery package of procedure 17110.
The Plan must follow Medicare rules. Medicare rules say that treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery, and clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications are not included in the global surgery package. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the photodynamic therapy have not been met. Specifically, services provided during the postoperative period which are unrelated to the original period must be billed with modifier -79. Since this was not billed with modifier -79, this is not payable as billed. Therefore, we decided that the Plan does not have to pay for the photodynamic therapy provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Muscle, myocutaneous, or fasciocutaneous flap (15734) provided on March 23, 2020.
You asked the Plan to pay for code 15734. You say that the medical records support the billing of code 15734. The Plan denied your request. The Plan says the medical records do not support the billing of code 15734.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for code 15734.
Our reviewer says that the medical records do not support the billing of code 15734. Our reviewer found the record indicates that a pedicle of falciform ligament was placed in the hepatic resection bed. This is not a Muscle, myocutaneous, or fasciocutaneous flap. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 15734 have not been met. Therefore, we decided that the Plan does not have to pay for the Muscle, myocutaneous, or fasciocutaneous flap (15734) provided on March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need a separately display (i.e., for alternate control
devices),other electronic devices (e.g., control of an augmentative speech device or computer through the
chair's drive control), or an attendant control. The enrollee has three approved power options on the wheelchair.
The enrollee's strength and function in the upper extremities with the ability to feed herself indicates that the
enrollee can control any power options through their own individual switches.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair and accessories for the enrollee
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on May 19, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that CP will attempt to consult with the enrollee's attending or primary care physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90834) provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7321), Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose.

You asked the Plan to pre-approve Hyaluronan or derivative. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Euflexxa, Supartz FX, Durolane, and Gelsyn-3.

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 Hyaluronan or derivative. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternatives. Therefore, the reviewer found that the requested drug is not medically necessary as step therapy criteria has not been 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 Hyaluronan or derivative have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative (J7321), Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits and 6 home health aide visits.

You asked the Plan to pre-approve additional home health care. You say that these additional services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage beyond what has been approved have not been met.

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 additional home health care. Our reviewer says that the requested home health care is not medically reasonable and necessary. Our physician reviewer found that based on the limited documentation provided, it appears that the enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). As such, the requested home health skilled nursing services, as well as any associated home health aide services, are not shown to be medically necessary, reasonable or coverable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 home health skilled nursing visits and 6 home health aide visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network office visit provided on February 19, 2021.

You asked the Plan to pay for these services. You say that you suffered a heart attack out of area and could not
return home until you were released to travel by the physician in that area. The Plan denied your request. The
Plan says this office visit was non-emergent for the purpose of follow up for which you did not have prior
authorization. Maximus overturned the Plans denial. The Plan requested a reopen and stated that while the
urgent and emergent services were communicated by you and covered by the Plan, you did not follow the Plan
contract rules when you scheduled and attended this follow up appointment, which was required by the Plan.

The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The prudent layperson rules do not apply to an office visit for follow up evaluation. The contract
with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care. In this case your emergency was over and the
medical records prior to this date of service showed you were stable for travel. You did not contact the Plan for
approval of this appointment for follow up or travel release. Therefore, we decided that the Plan does not have
to pay for an out of network office visit provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2740) for tooth #8 and #9.

You asked the Plan to pre-approve the crowns (D2740). You say that crowns are necessary due to gum recession. The Plan denied your request. The Plan says the crowns are not medically necessary.

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 crowns (D2740) for tooth #8 and #9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 26, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is no additional documentation that supports additional services beyond which have already paid.
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 an additional billed unit of CPT code 99232 is not supported in the medical record. Specifically, the documentation supports that 99232, as billed by the same provider, has already been processed for payment. The documentation does not support an additional unit of 99232 beyond what has already been paid. Therefore, this appears to be an exact duplicate of a previously processed claim. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met.
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 26, 2020.
Appeal type: Drugs
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 unilateral primary osteoarthritis of the right knee. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avsola.
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 step therapy requirement is not met.
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 rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. She has not tried and failed the Plan's required drugs, Remicade, Inflectra, or Simponi Aria. The records do not show that the required drugs would be contraindicated or less effective; therefore, Avsola 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 Avsola.