Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from February 13, 2020
to February 28, 2020.
You asked the Plan to pay for the physical therapy services. You say that the medical documentation
demonstrates medical necessity guidelines were met. The Plan denied your request. The Plan says there is a
lack of documentation to support the skilled needs of a therapist.
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 pay for the physical therapy services. Our reviewer
says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the requested therapy was not generally accepted as specific
therapy for the enrollee's condition. While the enrollee made some progress in therapy during the dates in
question, the documentation does not indicate his functional deficits required the unique skills of a professional
therapist to safely and effectively provide treatment. Services were repetitive and did not need to safely and
effectively be performed only by a therapist, or under the supervision of a therapist. The requested services
were not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified
therapist was not required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.
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 physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pay for physical therapy services provided from February 13, 2020 to February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (SEWHO) (L3960)
provided February 19, 2020.
You asked the Plan to pay for the orthosis. You say that this was denied for lack of medical records and you are
appealing. The Plan denied your request. The Plan says there is no actual physical exam. All information was
provided over the phone. The enrollee's geographical area is not an eligible area for telehealth services. There
is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines. There
is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Shoulder elbow wrist hand
orthosis (SEWHO) (L3960) provided February 19, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility or in-home with services.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuropathy support supplement purchased on March 19, 2021.  You asked the Plan to pay for the neuropathy support supplement. You say that you ordered the supplements and the pain decreased by over 90% without prescribed medication. You say that this works for you and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the neuropathy supplement, Alpha Lipoic Acid, is not listed as a covered item.  You have a $550 Pick Your Perks Benefit that is available for eligible over-the-counter items. The neuropathy support supplement is not listed as an eligible item. Therefore, we decided that the Plan does not have to pay for the neuropathy support supplement purchased on March 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from June 13, 2021, through June 23, 2021 and July 6, 2021, through July 12, 2021.  You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says there were no daily skilled needs.  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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the nursing facility appear custodial 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from June 13, 2021, through June 23, 2021 and July 6, 2021, through July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral for the evaluation and treatment of phrenic nerve paralysis to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an out of network referral for evaluation and treatment of phrenic nerve paralysis. You say that you would like reconsideration because the Plan referrals have not been successful. The Plan denied your request. The Plan says there are providers in-network available to render the necessary services.  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 provider at issue in this case is not a network provider with the Plan. 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 out of network referral for evaluation and treatment of phrenic nerve paralysis. Our reviewer says that The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer found the record indicates that you require an opinion from a pulmonologist. The Plan indicates that they have network physicians available.  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 out of network referral for evaluation and treatment of phrenic nerve paralysis have not been met.   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 an out of network referral for evaluation and treatment of phrenic nerve paralysis. Therefore, we decided that the Plan does not have to pre-approve a referral for the evaluation and treatment of phrenic nerve paralysis to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.  You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration because the enrollee has failed conservative treatment and the Vertiflex is a better alternative to traditional surgery. The Plan denied your request. The Plan says the requested procedure is 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 Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not document that the enrollee is not indicated for operative intervention at no more than two levels. The record indicates that the enrollee has unquantified scoliosis.  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 Superion Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.  You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage 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 use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation does not show that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 a Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ambulance services you received on July 19, 2021, and July 27, 2021.  You asked the Plan to waive the copayments for the ambulance services. You say that you have had ambulance services in the past and never had to pay anything. The Plan denied your request. The Plan says you were charged these copayments 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 a $250 copayment per trip for ambulance services.   You have been asked to pay a $250 copayment per trip for the ambulance services. These copayments apply regardless of what you may have paid in the past. 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 copayments for ambulance services you received on July 19, 2021, and July 27, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you remain critically ill and require acute care services. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility.  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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you feel that you need to stay at the SNF because you will be received two intravenous lines in your arm. The Plan denied your request. The Plan says the denial of authorization for additional SNF care is correct, because you have already received 100 days of covered SNF care in this benefit period.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that you received 100 days of SNF care during the benefit period from June 17, 2021 to November 24, 2021. The Plan has covered 100 days of SNF care.  Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care diagnosis related group (DRG) 871 with principal diagnosis code A41.9 provided from October 20, 2020, to October 26, 2020.  You asked the Plan to pay for inpatient hospital care. You say that the DRG of 871 is valid for this stay. The Plan denied your request. The Plan says the denial of payment for this inpatient DRG is correct, because code A41.9 is not supported as the principal diagnosis.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with A41.9 - sepsis, unspecified organism. 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 pay for inpatient hospital care. Our reviewer says that this inpatient stay does not meet criteria for payment at the requested diagnosis related group (DRG). Our physician reviewer found documentation does not support A41.9 sepsis, unspecified organism as a primary or secondary diagnosis. While the enrollee was in the emergency room, documentation supports sepsis could be a possibility due to hypotension and tachycardia; however, the enrollee improved while in emergency room. During the hospital stay, documentation did not include confirmation of sepsis. In this case, the documentation supports J18.9 pneumonia, unspecified organism instead.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care diagnosis related group (DRG) 871 with principal diagnosis code A41.9 provided from October 20, 2020, to October 26, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility.  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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the intercept device or code 22899 (other procedures of the spine vertebral column) for the enrollee.
You asked the Plan to provide coverage for this procedure. You say that the intercept procedure is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus upheld the case however named the Vertiflex device as the service in appeal. The Administrative Law Judge (ALJ) remanded to case back to Maximus for review of the intercept procedure.
Our Medical Director looked at the case file and the remand request from the ALJ. At issue is coverage for the intercept device or code 22899 (Other procedures of the spine vertebral column). The medical records show the enrollee is a 90-year-old woman with a diagnosis of Spondylosis without myelopathy or radiculopathy in the lumbar region. An Intracept intraosseous ablation procedure of the basivertebral nerve was proposed at the L3 vertebral level. The enrollee has a medical history of obstructive sleep apnea, hypertension, GERD, and Alzheimer's disease with significant cognitive impairment. The enrollee has disabling back pain which has been of long-term duration, despite previous treatments.
The enrollee has an "inability to successfully communicate response to temporary diagnostic nerve blocks." Imaging of the lumbar spine on April 13, 2020 showed levoscoliosis apex L2-3. Multiple levels of arthritis without findings of spinal canal stenosis. Borderline to mild neuroforaminal stenosis on the left at L4-5. Shallow far lateral disc herniation left L3-4. Modic type endplate changes at L3, L2, and L1 with significant disc degeneration. Milder Modic type 1 and type 2 endplate changes at the L4 and L5 levels. Our Medical Director has concluded that the Plans denial was correct. The available documentation does not support that the Intracept intraosseous ablation procedure is medically reasonable and necessary for the enrollee in this case. The evidence regarding the efficacy of the Intracept ablation procedure is inconclusive currently. In addition, the clinical documentation does not support that the procedure is reasonably expected to be at least as beneficial as existing and available medically appropriate alternatives for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this procedure have not been met. Therefore, we decided that the Plan does not have to provide coverage for the intercept device or code 22899 (other procedures of the spine vertebral column) for the enrollee.