Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hyalgan for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Part B coverage of the requested viscosupplement is subject to our step therapy criteria.  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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug.In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs likely be less effective and/or likely have adverse effects for the enrollee.  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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan for the enrollee.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a kidney transplant for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the resolution of the peritonitis and the current medical status are unknown.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is clearly a transplant candidate. This is documented in the records. There is no medical or social reason to deny transplantation to this enrollee. In this instance, transplantation is considered the standard 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 the surgery have been met. Therefore, we decided that the Plan has to pre-approve a kidney transplant for the enrollee.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided from May 7, 2021 to June 15, 2021.  You asked the Plan to pay for these services. You say that you thought these services were approved. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  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 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 out of network physician services provided from May 7, 2021 to June 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation care.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve any of the dental services under appeal.
You asked the Plan to provide coverage for several dental services. You say that these dental services are
necessary and should be covered by the Plan. The Plan denied your request. The Plan says other than those
approved, the dental services requested are not covered. Maximus partially overturned the Plans denial. The
Plan requested a reopen and provided additional information. The Plan states that code D4341for deep gum and
root cleaning (upper left quadrant) was denied because for this service to be covered, there must be at least four
natural teeth in the same part of the mouth that need treatment. The dental records show only one remaining
natural tooth and 3 implants in the upper left quadrant. Therefore, due to the lack of the required number of
natural teeth, the denial for root planing/curettage (deep cleaning) was correct. The American Dental
Association definition of code D4341 "periodontal scaling and root planing - four or more teeth per quadrant"
clearly eliminating the counting of implants which a) do not have roots and b) are specifically contraindicated
from scratching their surface and must be protected from even being touched by scalers during routine
cleanings.
The Plan is correct in this case. 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 based on the specific guidelines from the American Dental Association
regarding treatments that require the presence of natural teeth. Therefore, we decided that the Plan does not
have to provide coverage for any of the dental services requested other than those approved by the Plan.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum.  You asked the Plan to pre-approve diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum. You say that the ultrasound is medically necessary. The Plan denied your request. The Plan says based on the medical information received, medical necessity has not been established for a repeat abdominal ultrasound.  The Plan follows 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 diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum. Our reviewer says that diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum is not medically necessary. Our physician reviewer found that the enrollee is a 71-year-old female with anemia. Bone marrow biopsy and abdominal ultrasound were ordered and completed. Repeat diagnostic ultrasound procedures of the abdomen and retroperitoneum was requested. The medical records state that the enrollee's clinical presentation is suggestive of clonal cytopenia of undetermined significance. The enrollee is not significantly symptomatic and is reported to be stable. Due to there being no change or worsening of signs and symptoms to warrant additional ultrasound monitoring, this request for such will be considered not medically necessary 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 diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic ultrasound procedures, diagnostic ultrasound procedures of the abdomen and retroperitoneum.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on August 5, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.  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 drug testing (G0483) provided on August 5, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE), real-time with imaging documentation for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the physical exam demonstrated normal heart sounds and no lower extremity edema.  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 TTE from July 2021 was a technically satisfactory study interpreted by a cardiologist. The September 2021 clinic visit with the pulmonologist did not suggest any clinical changes which would have resulted in any expected difference in repeat TTE images compared with those of the July 2021 study. In summary, a repeat TTE is not clinically warranted and not considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE), real-time with imaging documentation for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that rehab will help you gain the strength back you originally had when you first arrived at the hospital. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diabetic supplies provided from November 4, 2020, to January 22, 2021.  You asked the Plan to pay for the services provided. You say that the supplier may use the shipping date as a billing date. The Plan denied your request. The Plan says the billed services cannot be verified.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided from November 4, 2020, to January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 15, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 26, 2021.  You asked the Plan to pay for the testing services. You say that the providers determine the enrollee required testing. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.  The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.  We looked at the file and the rules. In this case, there are insufficient medical records to show that the results of this testing would be used in the management of a specific medical problem. There are no records to show the enrollee was experiencing signs and symptoms that warranted the testing. Medicare does not cover this testing for screening purposes. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on December 10, 2020.  You asked the Plan to pay for the services provided. You say that you do not accept walk-ins and do not have access to the enrollee's demographics. The Plan denied your request. The Plan says the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records provided do not indicate the enrollee's specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the enrollee is medically clear for discharge to a SNF, which is the necessary level of care for the enrollee's safety. The Plan denied your request. The Plan says the records do not show that the enrollee needs either skilled nursing or rehabilitation care daily.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had routine foley catheter care. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a supervision level with functional mobility including gait to 240 feet. The enrollee required varying assist with activities of daily living.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the WATS-3D testing (88361) provided on March 30, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's available record supports the high likelihood of Barrett's esophagus, and thus meets the spirit of the American Society for Gastrointestinal Endoscopy (ASGE) guidance relative to medically necessary use of WATS-3D in this case. Finding that his Barrett's has potentially progressed will positively impact the enrollee's care going forward.  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 testing have been met. Therefore, we decided that the Plan has to pay for the WATS-3D testing (88361) provided on March 30, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomics testing services provided on June 21, 2021.  You asked the Plan to pay for the testing services. You say that the test can prevent dangerous medication interactions. The Plan denied your request. The Plan says predictive screening is not a Medicare benefit. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We looked at the file and the rules. The records provided indicate the testing was ordered to predict disease prognosis and eliminate potential adverse drug effects. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a patient's response to the medication. It is not necessary to do genetic testing to provide or adjust medications. Furthermore, genetic markers may or may not correlate with actual clinical findings. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing services provided on June 21, 2021.