Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a plastic surgery consultation to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist visit. You say that your wound is turning red, and you are suffering from severe pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network plastic surgery specialist.

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 a plastic surgery consultation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the lower limb prosthesis with an advanced foot.  You asked the Plan to pre-approve the lower limb prosthesis with an advanced foot. You say that you would like reconsideration because the requested prosthesis is medically necessary. The Plan denied your request. The Plan says the documentation does not show why the requested advanced foot is needed.  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 lower limb prosthesis with an advanced foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the member's medical need as the treating medical provider documentation  does not support that this member is a level K3 ambulator. The documentation indicates that the member was authorized a recent power mobility device in August of 2021, has not ambulated in a year, and the medical provider documentation makes no mention of the member's K level.  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 lower limb prosthesis with an advanced foot have not been met. Therefore, we decided that the Plan does not have to pre-approve the lower limb prosthesis with an advanced foot.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is the enrollee's best option to improve their pain thus improving the enrollee's daily living. The Plan states this procedure is done every day across the country with excellent results; you need to obtain approval soon to allow the enrollee's decline in physical ability to stop and improve their mental well-being with decreased pain and increased activity. 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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on April 9, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.   We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 pay for the drug testing services provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 2 power wheelchair.  You asked the Plan to pre-approve Group 2 power wheelchair. You say that the enrollee would benefit from a power wheelchair to help complete activities of daily living. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee meets the criteria for a power operated vehicle (which was recommended) and therefore does not meet the criteria for a power wheelchair.  The Plan follows Medicare rules. Medicare rules state that power wheelchairs may be covered for enrollees who meet certain criteria do not meet criteria for use of a power operated vehicle.  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 Group 2 power wheelchair. Our reviewer says that the enrollee does not meet the Medicare criteria for a Group 2 power wheelchair. Our physician reviewer found the records indicate the enrollee can safely transfer to and from a power operated vehicle, operate the tiller steering system, and maintain postural stability/position while operating a power operated vehicle in the home. The enrollee appears to meet the criteria for a power operated vehicle (such as a motorized scooter) instead of a power wheelchair.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 11, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 0242U is targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements.  We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a manual wheelchair.
You asked the Plan to provide coverage for a manual wheelchair. You say that a manual wheelchair is
medically necessary. The Plan denied your request. The Plan says there were no medical records or physician
order provided to support your need for a manual wheelchair. Maximus overturned the Plans denial due to a
lack of medical records. The Plan requested a reopen and stated that the case file documented several attempts
to have your physician provide medical records and the evaluation required by Medicare to approve a manual
wheelchair.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare requires specific medical
record documentation and home evaluation for approval of a manual wheelchair. This must be facilitated by
your physician. The record does not contain a valid physician order relevant medical records which support
medical necessity for the manual wheelchair requested. 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
provide coverage for a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 5, 2020, and November 12, 2020.  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 November 5, 2020, and November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve RT3000 Home Therapy Ergometer Functional Electrical System.  You asked the Plan to pre-approve these services. You say that this has been cleared as safe and effective. The Plan denied your request. The Plan says that you do not meet criteria for coverage of these services.  The Plan must follow Medicare rules. Medicare rules say that a functional electrical stimulator is covered when the NCD criteria are met.  We looked at the file and Medicare rules. The file does not indicate you are using this to treat muscle atrophy where nerve supply to the muscle is intact or being used to help walking because of a spinal cord injury. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve RT3000 Home Therapy Ergometer Functional Electrical System.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program.
There is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided on February 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the inpatient services. You say that there was miscommunication as you did not realize that authorization was required so you are requesting review of the documentation attached and a one time exception of this error. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the inpatient hospital care provided on February 9, 2021 by an out-of-network (OON) provider.
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 the requested services. You say that you cannot function without the injection. The Plan denied your request. The Plan says radiofrequency ablation at this level was successful.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications.  The file shows that diagnostic injections at L4-L5 were requested. 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 you have low back pain secondary to lumbar spotreated with medical therapy including opiates, a home exercise program, and physical therapy. The records do not show that the requested treatment is indicated for your condition. You had a radiofrequency ablation procedure at L4-L5 on September 22, 2021, which was successful. There are plans to perform this procedure on the other side. Diagnostic procedures at this same level are therefore not 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion therapy (procedures code S9329, S9330, A4223).  You asked the Plan to pay for the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says these codes are not valid for Medicare purposes.  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 the denied codes is:  Healthcare Common Procedure Coding System (HCPCS) S9329:  Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem  HCPCS S9330:  Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem  HCPCS A4223:  Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)  We find that the denied codes are not supported in the medical record. Specifically, codes S9329 and S9330 have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Additionally, A4223 has a status indicator of "X" which means that the code is statutorily excluded from coverage. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (procedures code S9329, S9330, A4223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 4, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. 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 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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation indicates that the services are not authorized because predictive screening testing is
not a Medicare benefit.
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 pay for laboratory services provided to the enrollee on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IDPN (CPT code(s): B4189, B4185, B4224, B4199), for
the enrollee.
You asked the Plan to pre-approve the service. You say that IDPN is necessary to meet the enrollee's nutritional
needs while balancing the protein losses due to hemodialysis. You state the enrollee continues to present with
hypoalbuminemia despite dietary counseling and increased oral intake of protein and oral supplements. The
Plan denied your request. The Plan says the requested services are not medically necessary because based on
documentation provided it appears that there is no disease involving the enrollee's stomach or small intestine
and the enrollee has not tried tube feeding.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the service have not been met. Parenteral nutrition is noncovered
for the enrollee with a functioning gastrointestinal tract whose need for parenteral nutrition is only due to renal
failure and/or dialysis. Therefore, we decided that the Plan does not have to pre-approve IDPN (CPT code(s):
B4189, B4185, B4224, B4199), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this meets the requirements as being medically
reasonable and necessary. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because studies have not proven that Vertiflex is helpful for treatment of the enrollee's
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 Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no documentation of the enrollee's height or body-mass index. There is imaging
evidence of mild levoscoliosis of the lumbar spine, with no documentation of the Cobb angle. There is
documentation of osteoporosis, but no discussion indicating that a dual-energy X-Ray absorptiometry (DEXA)
scan has demonstrated the lack of significant osteoporosis in the enrollee. There is no compelling rationale
presented or extenuating circumstance noted to support the medical necessity of this request as an exception to
guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure.