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

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you would like to avoid going into surgery. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 pre-approve additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have intermittent right shoulder pain currently at 0 out of 10 and at worst it is 6 out of 10. The documentation shows that you have had no changes in range of motion. The documentation does not support that you meet criteria for the requested physical therapy visits for the treatment of right shoulder pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide to be provided at a lower cost level.

You asked the Plan to pre-approve Budesonide to be provided at a lower cost level. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested tier exception is not a covered benefit.

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.

In this case, you have requested Budesonide to be provided at a tier exception (at a lower cost level). Tier exceptions are only available for Part D drugs. Budesonide is not considered a Part D drug. Therefore, we decided that the Plan does not have to pre-approve Budesonide to be provided at a lower cost level.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis; with contrast material(s) (74177).

You asked the Plan to pre-approve a CT scan of the abdomen/pelvis. You say that the enrollee needs an updated CT scan. The Plan denied your request. The Plan says the requested CT scan is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen/pelvis. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has adrenal carcinoma and is scheduled for surgery. The record indicates that the enrollee had a CT abdomen August 16, 2021, and a magnetic resonance imaging (MRI) of the abdomen on August 25, 2021. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. 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 CT scan of the abdomen/pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis; with contrast material(s) (74177).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry.

You asked the Plan to pre-approve cardiovascular telemetry. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not necessary to document symptomatic arrhythmia and the enrollee does not have contraindications to available alternatives.

The Plan follows Medicare rules. Medicare rules state that cardiac telemetry may be covered under certain conditions. 

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 cardiovascular telemetry. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested cardiovascular telemetry. Our physician reviewer found the records do not indicate that the enrollee has a covered indication for this testing. The records do not support the medical necessity and reasonableness of this service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiovascular telemetry have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT code 64636), for the enrollee
.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee had two injections of numbing medicine.

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 items/services are not considered medically reasonable and necessary in this case.

Our physician reviewer found the request for radiofrequency ablation (RFA) of the lateral sacral branches is considered experimental/investigational. Therefore, the request is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (CPT code 64636), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglass frames (V2020),
spherocylinder lenses (V2107), anti-reflective coating (V2750) and bifocal lenses (V2207, V2211) provided on
March 5, 2021.

You asked the Plan to pay an additional amount for eyeglass frames, spherocylinder lenses, bifocal lenses and
anti-reflective coating. You say that the Plan advised you had vision benefits and the eye doctor confirmed
benefits. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for
the remaining balance.

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 contract says you have a $300 allowance once per year to use towards the purchase of
eyeglasses or contact lenses.

We looked at the file and the Plan's rules. The records show you exhausted your $300 maximum allowed
benefit on March 5, 2021. The records also show that you purchased frames at $350, sphere bifocal lenses at
$219, spherocylinder bifocal lenses at $119 and an anti-reflective coating at $109, for a total amount of $797
($350 + $219 + $119 + $109 = $797). The Plan applied your $300 allowance which left you a balance of $497
($797 - $300 = $497). The provider also applied an additional discount of $153.20 which brings your total cost
share to $343.80 ($497 - $153.20 = $343.80). Based on this information, we decided that the Plan's rules for
coverage of eyeglass frames, spherocylindar lenses, bifocal lenses and anti-reflective coating have not been
met. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglass frames
(V2020), spherocylinder lenses (V2107), anti-reflective coating (V2750) and bifocal lenses (V2207, V2211)
provided on March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee required stand-by assistance to walk 200 feet with a rolling walker. The enrollee required supervision for transfers. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that the enrollee requires skilled nursing or skilled therapy services on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 23, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the testing was medically necessary. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory Place of Service code while the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
December 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botulinum toxins (Botox).
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications.
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 Botox. Our reviewer says that the
documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee was diagnosed with diabetic related gastroparesis. The requested Botox
is being requested to the pylorus for treatment. The clinical value and effectiveness of Botox in the setting of
gastroparesis have not been demonstrated in the peer-reviewed literature. The enrollee does not have a
diagnosis/condition that meets criteria for Botox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botulinum toxins (Botox).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on May 13, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you have never had to pay for X-rays in the past. 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 $15 copayment for X-rays. You have been asked to pay a $15 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an X-ray provided on May 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomography of the heart without contrast, with a quantitative evaluation of coronary calcium (75571).
You asked the Plan to pre-approve the calcium scoring. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says Calcium scoring reported in isolation is considered a screening service. The test is never covered for screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the calcium scoring, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve Computed tomography of the heart without contrast, with a quantitative evaluation of coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee would benefit from a home compression pump. Her condition is severe and meets the need for lymphedema pumps. The Plan denied your request. The Plan says a PCD coded as E0652 is not covered for lymphedema of the extremities alone. There is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain indications. 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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee had a prior cervical radiofrequency ablation that apparently did not produce long lasting results and now the physician wants to perform cervical facet injections. This is not the standard of care approach. Therefore, the enrollee does not meet criteria for the requested 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 facet joint injections have not been met. Therefore, we decided that the Plan
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unlisted evaluation and management, massage therapy services (99499).
You asked the Plan to pre-approve the massage therapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested massage therapy services is not attached to a specific PT or OT modality for back pain and is not covered.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve the unlisted evaluation and management, massage therapy services (99499).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for air ambulance services provided on May 20, 2021.
You asked the Plan to waive the coinsurance for air ambulance services. You say that the hospital should be responsible for the charges due to the pain and suffering you underwent. 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 20% coinsurance for air ambulance services. You have been asked to pay $516.41, which is less than the 20% coinsurance for air ambulance services. Air ambulance services falls within the ambulance services 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 coinsurance for air ambulance services provided on May 20, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) additional PT visits.
You asked the Plan to pre-approve seven (7) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 pre-approve seven (7) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your 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 seven (7) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven (7) additional PT visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on May 18, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you were never informed that you would now owe a copayment for telehealth visits. 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 $10 copayment for primary care provider visits, including telehealth visits. You have been asked to pay a $10 copayment for an office visit. An office 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 an office visit provided on May 18, 2021.