Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676 and E0673).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services received on February 8, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services received on February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that at the time of the appeal,
skilled nursing facility services were medically necessary. The Plan denied your request. The Plan says
Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen
and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for skilled nursing
facility (SNF) services. The Maximus Physician Reviewer determined there were skilled therapy needs and that
you appeared to be functioning below your baseline. The Plan argues that you did not require daily skilled
nursing or skilled therapy in a SNF setting. The services required were considered custodial care, as there was
no need for daily skilled therapy.
The medical records show you have a history of hypertension, hyperlipidemia, and chronic kidney disease. You
were admitted to the hospital on July 29, 2021 following a syncopal episode. You had progressive decline in
functional, nutritional, and mental status, especially in the previous year. While in the hospital you had an
episode of hypotension, and an episode of altered mental status and hypoxia. There was a decline toward
occupational therapy goals. At that point you required maximum assistance for daily activities. The discharge
recommendation was home health services.
Our Medical Director has concluded that the Plan is correct in this case. The documentation in the case file is
insufficient to support that you required skilled services daily on an inpatient basis in a skilled nursing facility
setting. Medicare coverage criteria were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July 7, 2021.
You asked the Plan to pay for CT scan 70450. You say that this procedure was medically necessary and an appropriate modifier was applied. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so is not separately payable without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code CT
scan 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July 7, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313,
E2377) 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 this is 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the provided records document that the enrollee has 3+/5 to 4/5 upper extremity strength and is
independent with feeding thus indicating she has adequate upper extremity strength and function to operate the
wheelchair's power options with their own switches.
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 additional power wheelchair accessories (E2313, E2377) for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested IRF 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 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 four gingival irrigations (D4921 x4) provided on July 26,
2021.
You asked the Plan to pay for the gingival irrigations. You say that you feel that the Plan has a pattern and
practice of denying services advertised as covered on their website and/or providing misinformation and/or
ambiguity of various dental procedures listed as covered. The Plan denied your request. The Plan says this
service is not a covered benefit under your dental plan.
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 the four
gingival irrigations (D4921 x4) provided on July 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Therapy (PBT).
You asked the Plan to pre-approve the PBT. You say that you would like reconsideration because the requested treatment is medically necessary. The Plan denied your request. The Plan says the member is not enrolled in a clinical trial.
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 PBT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found photon beam therapy options exist for this member. 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 PBT have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Therapy (PBT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve parenteral nutrition services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve parenteral nutrition services. You say that these services are necessary with an OON provider. The Plan denied your request. The Plan says there are multiple in-network providers available to treat your medical condition.
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve parenteral nutrition services to be provided by an out-of-network (OON) provider.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet all of the Medicare criteria for admission to this facility.
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 have any major acute medical issues, and does not meet the coverage criteria for this admission. With the enrollee's medical stability after the motor vehicle accident, there is no need for physician supervision three times a week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation or nursing needs noted in the record. The enrollee did not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. His therapy needs could have been easily and safely provided in a skilled nursing facility (SNF). IRF admission was not medically necessary based on lack of medical complexity and nursing needs. The enrollee's needs could have been safely provided in an alternate and low intensity setting such as in an SNF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient reliable evidence to support this procedure.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational and two learned societies do not support its use in spinal stenosis. Therefore, the request is deemed 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation 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 there are no subsequent right sided medial branch blocks documented in the medical
records.
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 that in this case, the enrollee underwent radiofrequency ablation of the right L2-3-4-5 facet nerves in
May 2019. There were no subsequent right-sided medial branch blocks documented.
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 radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced knee feature (L5822, L5845, L5850).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 knee does not meet Medicare criteria as reasonable and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee is a K3 ambulator. No medical records from the enrollee's treating physician were provided documenting K3 level function. 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 an advanced knee feature (L5822, L5845, L5850).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time billed with code 99072 for dates of service March 25 - April 19, 2021.
You asked the Plan to pay for the additional supplies, materials, and clinical staff time. You say that additional charges were incurred in addition to what would normally be billed in an office visit. You say that the additional supplies and materials were used due to the public health emergency. The Plan denied your request. The Plan says the code billed is disallowed when billed in conjunction with other procedure codes and a modifier of 59 is not wallowed to override these edits.
The Plan must follow Medicare rules. Medicare rules say that payment for a code with a status indicator of B is always bundled into payment for other services.
We looked at the file and Medicare rules. The code that is in dispute has a status indicator of B. This means that payment for the services represented by this code is bundled into payment made on other services provided. Based on this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time billed with code 99072 for dates of service March 25 - April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 Vertiflex spacer 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health, and home physical 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for spinal stenosis and COVID 19 infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.