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

We decided that the Plan does not have to pay for the cardiovascular risk assessment services (81286, 81238, 81410 and 81411) provided on May 20, 2021.

You asked the Plan to pay for the cardiovascular risk assessment services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk screening assessment genomic testing panels for suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that all cardiovascular (CV) risk assessment panels will be denied, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment services have not been met. Specifically, the services billed are not a basic lipid panel. Medicare denies coverage for all cardiovascular (CV) risk assessment panels except the basic lipid panel. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment services (81286, 81238, 81410 and 81411) provided on May 20, 2021.
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 are not stable enough to walk. The Plan denied your request. The Plan says the records do not support the need for an intensive rehabilitation therapy program.

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 physician reviewer found that you were admitted to the acute care hospital for osteomyelitis. With your current medical stability, there is no need for rehab physician supervision 3 times per week. At the current functional level of function, you do not require intensive therapies, with multidisciplinary approach to daily therapy.

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 pre-approve an anterior cervical discectomy and fusion.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that magnetic resonance imaging (MRI) does not show any evidence of severe nerve root or spinal cord compression. There is no correlation between MRI imaging and a physical exam completed for the enrollee. Therefore, an anterior cervical discectomy and fusion surgery is not medically 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an anterior cervical discectomy and fusion
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for these dental services.

You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct.
The Plan denied your request. The Plan says this cost share was appropriate because you were treated by an
endodontist specialist and not a general dentist. Therefore, the copayment would be $425. Maximus partially
overturned the Plans decision and instructed a deduction. The Plan requested a reopen and provided additional
information showing the cost share was charged based on the services provided and the Plan contract.

We reviewed the services billed by the provider and the Plan contract agreement. The Plan is correct in this
case. Medicare generally does not cover dental services. The Plan offers a dental benefit that exceeds Medicare
coverage. For that reason, the Plan's coverage rules apply in this case. Based on the claim submitted by the
provider and the Plan contract agreement, the copayment for code D3348 provided by an endodontist is $425.
In addition, code D9630 is not covered.

Therefore, we decided that the Plan does not have to waive or reduce the cost share charged for any of these
dental services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits.
You asked the Plan to pre-approve 3 home health skilled nursing visits. 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 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 3 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent 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 3 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health skilled nursing visits
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical performance testing provided on May 19, 2021, billed with code 97750.
You asked the Plan to pay for the testing as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the billing of code 97750.
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 97750 is Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes. 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 the testing as billed. Our reviewer says that the documentation does not support the use of this code. Our reviewer found documentation includes a Musculoskeletal Ultrasound Imaging Report, this is an inappropriate code to report for this service. There is a
more appropriate code to report for service rendered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the physical performance testing provided on May 19, 2021, billed with code 97750
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on May 14, 2021.
You asked the Plan to pay for the eye refraction. You say that this provider is in-network, and this service should be covered. The Plan denied your request. The Plan says the provider in this case is part of the Plan's medical network but is not part of the Plan's specified routine vision vendor network. The exam and office visit have been processed under your medical benefits, but the eye refraction is denied as this service is not covered by Medicare.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are performed by a provider in the Plan's specified routine vision vendor network. Out-of-network supplemental vision care is not covered. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified supplemental vision network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on May 14, 2021.
Your complaint about potential confusion between the Plan's medical network and supplemental network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 home health physical therapy visits and 9 home health skilled nursing visits.
You asked the Plan to pre-approve 12 home health physical therapy visits and 9 home health skilled nursing visits. 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 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 12 home health physical therapy visits and 9 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent 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 12 home health physical therapy visits and 9 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 home health physical therapy visits and 9 home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial liver resection provided on May 22, 2021, billed with code 47120.
You asked the Plan to pay for the surgical services as billed. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says code 47120 is not supported.
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 47120 is Hepatectomy, resection of liver; partial lobectomy.
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 the surgical services as billed. Our reviewer says that the billed code is not supported based on the records. Our reviewer found the documentation does not include an operative report with Hepatectomy; partial lobectomy performed. To cite the available documentation: "Procedure Details: Major Hepatice Resection: Segmentectomy Sements Removed 4b/5 Parenchymal Transection: Kelly Crush Tissue Link". Details of this procedure are not documented, and therefore, the code cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the partial liver resection provided on May 22, 2021, billed with code 47120.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is 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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate the procedure's 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
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. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that you were admitted to the acute care hospital with a urinary tract infection, confusion, and a fall. You require moderate assist for toileting, minimal assist for transfers, and moderate assist for toileting.
With your current medical stability, and no medical complexity, there is no need for a rehab physician supervision 3 times per week. At the current functional level of function, you do 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. 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 pre-approve a Vertiflex device for the enrollee.
You asked the Plan to pre-approve a Vertiflex device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.
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 a Vertiflex device. Our reviewer says that the requested device is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. 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 ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found 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 bilevel positive airway pressure (BiPAP) machine with average volume assured pressure support (AVAPS) capability. The prescriber submitted a conclusory statement addressing the technical differences of the requested device without enrollee specific justification. The plan has indicated coverage is available for such a device. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq and Abraxane.
You asked the Plan to pre-approve Tecentriq and Abraxane. 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 a drug or biological only if it is safe and effective and otherwise reasonable and 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 Tecentriq and Abraxane. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq and Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq and Abraxane
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve a prefabricated abutment and an abutment supported porcelain/ceramic crown. You say that you have an implant on tooth #14 and it is required that you get a crown placed. You also say that you have the benefits available on your plan and your remaining balance will cover the service. The Plan denied your request. The Plan says the requested services are not listed in the handbook and therefore are not covered services.
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 a prefabricated abutment (D6056) and an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not proven to be helpful for your condition.
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 insertion of a Vertiflex device. Our reviewer says that the requested 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 it is safe and 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on July 26, 2021.
You asked the Plan to pay for dental service. You say that this was a necessity for your healthy living. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by the Plan's dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on July 26, 2021.