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

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve MRI. You say that an X-Ray will not show you what you need to see so an 
MRI is needed. The Plan denied your request. The Plan says the denial of authorization for this test is correct, 
because the documentation does not support the medical necessity of this MRI. 
 
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 MRI. Our reviewer says that the 
enrollee does not meet the Medicare criteria for this MRI. Our physician reviewer found the record indicates 
that the enrollee underwent a T10 and T11 laminotomy with decompression. The enrollee is improving. The 
records do not show that this MRI is medically reasonable or necessary for the diagnosis and treatment of the 
enrollee's condition 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial hospitalization program.
You asked the Plan to pre-approve partial hospitalization program. You say that disruption in care will continue to harm you. The Plan denied your request. The Plan says the denial of authorization for partial hospitalization program is correct, because you are only required to attend care for less than 10 hours per week and your risks could be managed in an outpatient mental health program.
The Plan follows Medicare rules. Medicare rules state that partial hospitalization programs may be covered for enrollees who meet certain eligibility criteria. 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 partial hospitalization program. Our reviewer says that you do not meet the Medicare criteria for a partial hospitalization program. Our physician reviewer found it is not expected that you would improve in a reasonable period of time beyond September 9, 2021 as you were not showing any dangerousness to yourself or others tolerative medication and not showing any perceptual disturbance, psychosis, or aggressive behaviors. It does not appear medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care rather than 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 partial hospitalization program have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial hospitalization program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional extremity study (93970) provided on April 21,
2021.
You asked the Plan to pay for the additional extremity study. You say that you would like reconsideration
because this claim denied as a duplicate in error. The Plan denied your request. The Plan says the
documentation does not support that an additional extremity study was rendered on the billed date of service.
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 93970 is duplex scan of extremity veins including
responses to compression and other maneuvers; complete bilateral study.
We find that CPT code 93970 is not supported in the record. Specifically, the record supports one extremity
study was rendered on the billed date of service. One unit has been processed and paid by the Plan. The record
does not indicate that an additional unit of CPT code 93970 was rendered. Based on this information, we
decided that Medicare rules for coverage of the additional extremity study have not been met. Therefore, we
decided that the Plan does not have to pay for the additional extremity study (93970) provided on April 21,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator.  

You asked the Plan to pre-approve a ventilator. You say that the enrollee has severe chronic respiratory failure. 
The Plan denied your request. The Plan says a home ventilator in AVAPS mode that could be delivered by 
BiPAP is not covered.  

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  

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 physician reviewer 
found that in this case, the record indicates that the enrollee has chronic respiratory failure from chronic 
obstructive pulmonary disease. The provided records indicate that the enrollee requires average volume-assured 
pressure support (AVAPS) settings.  The provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with AVAPS capability. Therefore, the requested ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable home ventilator.
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 request is medically necessary. 
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 of these devices. 

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-Syn 3 injections.
You asked the Plan to pre-approve the Gel-Syn 3 injections. You say that this should be approved. The Plan denied your request. The Plan says only preferred agents can be covered.
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 the Gel-Syn 3 injections. Our reviewer
says that the use of the non-preferred agent is not supported as step therapy criteria are not met. Our physician
reviewer found there is no evidence that the preferred agents have been tried, nor that they would be less
effective.
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 Gel-Syn 3 injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Gel-Syn 3 injections
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve spinal cord stimulator. You say that this will help with your pain. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because there is no
evidence of at least 50% reduction of pain to support a spinal cord stimulator.
The Plan follows Medicare rules. Medicare rules state that only patient who experience a positive response to a
trial should proceed to permanent spinal cord stimulator implantation.
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 spinal cord stimulator. Our reviewer
says that you do not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer found the
record indicates that you did not achieve pain relief with the stimulator trials and had poor tolerance of them.
The record does not contain adequate documentation to support permanent implantation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spinal cord stimulator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99053, 93042) provided January 27, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
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, we have confirmed that code 93042 has a bundled relationship with code 93010 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. CPT code 99053 has a status indicator of "B" per the CMS Physician Relative Value File and payment is always bundled with the primary service. Therefore, we decided that the Plan does not have to pay for physician services (99053, 93042) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service for a patient of extreme age (99100) provided on January 25, 2021.
You asked the Plan to pay for the anesthesia service for a patient of extreme age. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Payment for this service is always bundled into payment for other services not specified.
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 CPT code 99100 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99100 has a status indicator of B. This means that payment for CPT code 99100 is always bundled into another service. Based on this information, we decided that Medicare rules for coverage of the anesthesia service for a patient of extreme age have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia service for a patient of extreme age (99100) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 23, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because of the quality of care you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 a $45 copayment for specialist visits. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 copayment for a specialist visit provided on March 23, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit Maximus to make a decision on this type of complaint
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99214) provided on February 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 the office or other outpatient visit (99214) provided on February 9, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81230, 81231,
81328) provided on November 24, 2020.
You asked the Plan to pay for a pharmacogenetic panel. You say that this was medically necessary. The Plan
denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a
patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so 1 code must be submitted for the panel.
We find that CPT codes 81225, 81226, 81230, 81231, and 81328 are not supported in the medical record.
Specifically, these codes were used to report a panel, which should be billed with one code. Based on this
information, we decided that Medicare rules for coverage of a pharmacogenetic panel have not been met.
Therefore, we decided that the Plan does not have to pay for a pharmacogenetic panel (81225, 81226, 81230,
81231, 81328) provided on November 24, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not a covered benefit. 

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
We looked at the file, and Medicare rules. A power seat elevation system is not primarily medical in nature. 
Based on this information, we decided that Medicare rules for coverage of the requested services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide an additional center day per week.
You asked the Plan to provide an additional center day per week. You say that you want to get out of the house and the program is fun and different. The Plan denied your request. The Plan says you already attend once a week and you receive a home aide visit and nurse visit weekly.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional center day per week have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to provide an additional center day per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-based composite, one surface, posterior (D2391) for tooth #27.
You asked the Plan to pre-approve the dental services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the filling code used is not covered for tooth 27.
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 resin-based composite, one surface, posterior (D2391) for tooth #27.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the requested services. You say that you have fallen multiple times and it is hard for you to get around. The Plan denied your request. The Plan says coverage criteria 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 looked at the file, and Medicare rules. In this case, the records do not include a physician's order that specifies medical treatments, the type of service needed, and for how long services will be needed. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on December 9, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the documentation does not include definitive laboratory results of 22 or more drug classes to support code G0483. Code 80307 was already performed and submitted for the same date of service, meaning this service is a duplicate and is not payable. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on December 9, 2020.
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 you would like the IRF care covered. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. 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 percutaneous implantation of neurostimulator electrode
array, epidural - CPT4 (CPT code 63650).
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan
denied your request. The Plan says your request is not medically necessary because your records do not
document that you have had a psychological evaluation to say whether you are a good candidate for this device.
The Plan states it is not clear that this procedure option is being used as a last resort as treatment for your pain,
given the lack of evidence of your trying a variety of other treatment modalities.
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 service. Our physician reviewer
found the documentation provided did not show that you had completed and passed a psychological evaluation
to say whether they were a good candidate for this device. It was not clear from the documentation that all
other treatment modalities (besides pain medications) had been exhausted to justify this procedure. Therefore,
this request for Spinal cord stimulator trial will be considered not medically necessary at this time and based on
the provided documentation.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural - CPT4 (CPT code
63650).