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

 
We decided that the Plan has to pre-approve a functional electrical stimulator 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request cannot be approved at this time by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided any of the appropriate medical records this case. They 
have provided the handwritten appeal plea, a letter from the provider arguing medical necessity, and a letter 
from the vendor regarding medical necessity. The plan says that they looked at records that included office visit 
notes, test results, and treatment. None of these records were included in the case file that was sent to 
MAXIMUS. Therefore, we decided that the Plan has to pre-approve a functional electrical stimulator  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.

You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management.

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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve dialysis services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network dialysis centers available to the enrollee that can provide the care and treatment being requested. The Plan approved 90 days with the OON provider requested to help transition to an in-network provider.

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 dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve the complete upper and lower dentures. You say that you are in pain and 
urgently need new dentures. You say that the dentures you currently have do not fit and it has been months 
since you started to try and get dentures that do not hurt. The Plan denied your request. The Plan says the 
benefit for dentures is exhausted for the 2022 plan year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for complete dentures is 
limited to 1 upper complete and 1 lower complete denture every 5 years. The records show that you received 
coverage for complete dentures provided on October 1, 2021. This means that 5 years have not passed since the 
Plan covered complete dentures, and that your request exceeds the benefit allowance. Therefore, we decided 
that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says Ondansetron is not covered by Medicare or the health plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron. 

Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF admission.

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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found clinical documentation shows that the enrollee has multiple active comorbidities. Blood pressure continues to be labile per documentation and close medical monitoring on an inpatient basis during hospitalization would be expected to be required. Evaluating therapists (physical therapy, occupational therapy) recommend greater than 3hrs of therapy per day thus IRF criteria have been 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection of sclerosant.

You asked the Plan to pre-approve injection of sclerosant. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries are either compressive sclerotherapy or microphlebectomy.

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 injection of sclerosant. Our reviewer says that the services are not medically necessary. Our physician reviewer found coverage requires that truncal reflux in the saphenous and accessory saphenous veins are to be treated or not present prior to sclerotherapy. Additionally, there has to be documentation that after the truncal reflux is addressed, the enrollee continues to have significant symptoms despite treatment of reflux and 6 weeks of conservative efforts in the absence of reflux. The health plan does not provide coverage for simultaneous sclerotherapy and truncal reflux treatment. A rationale for this is that many patients may experience satisfactory improvement with truncal reflux treatment alone. Additionally, coverage criteria require that the veins to be treated with sclerotherapy be 4 millimeters in diameter greater. The documentation does not demonstrate this.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection of sclerosant have not been met. Therefore, we decided that the Plan does not have to pre-approve injection of sclerosant.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 knee replacement surgery. 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, in 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.

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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and related accessories. 
 You asked the Plan to pre-approve an expandable controller and related accessories. You say that this device is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for an 
expandable controller have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 an expandable controller and related 
accessories. Our reviewer says that the requested expandable controller is not medically reasonable and 
necessary. Our physician reviewer found that the expandable controller (E2377), expandable controller harness 
(E2313), and electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or 
compact joysticks, touchpads, chin control, head control, etc.) are not medically necessary. The patient does not 
require non-proportional input devices (e.g., sip and puff, head array, etc.).The patient does not require a 
separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative 
speech device or computer through the chair's drive control), or an attendant control. The wheelchair has 3 
power options of tilt, recline, and power elevating leg rests but the patient does not need to control the power 
options through a joystick. The patient's upper extremity strength and function support that the patient can 
control any power options through 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 an expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller and related accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 13 home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that additional home health services are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no 
medical need for additional home health services beyond what have already been approved. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the requested home health services are not medically reasonable and necessary. Our physician 
reviewer found based on the documentation provided, the enrollee does not have documented, ongoing, home 
health physical therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As 
such, the requested, ongoing, home health physical therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 13 home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee has a broken leg, and they cannot put
weight on it. You say the enrollee needs IRF care. The Plan denied your request. The Plan says an IRF
admission is not medically necessary, and the enrollee's needs can be met at an alternate level of 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 that the enrollee's medical problems are stable, and they do not require ongoing
physician supervision for management of any active or acute exacerbations of chronic medical conditions.
While the enrollee would benefit from physical or occupational therapy, their rehab needs can be safely
provided in an alternate 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has increasing low back pain, 
left hip pain, and radicular symptoms. She has had physical therapy (PT) with no success. Of concern is her 
diminished left patellar reflex, left leg weakness and positive left straight leg raise, which are red flags and PT 
has been tried. A lumbar spine x-ray was negative. The requested MRI of the lumbar spine is reasonable and 
medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the lumbar spine.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the
enrollee. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been
met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no
additional services.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found transfer to the LTACH is not medically necessary as the patient is not yet stable and
as it would not be clinically advantageous at this time. Completion of treatment at the current facility is
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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care (99291) provided on April 13, 2021.

You asked the Plan to pay for the critical care. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says payment will not be provided for services that were not received within 12 months or 1 calendar year from the date the services were furnished.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the critical care was not filed until May 18, 2022. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the critical care (99291) provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of an erupted tooth (D7210), surgical 
placement of an implant (D6010), an interim partial upper denture (D5820), and a cone beam computed 
tomography (CT) scan of both jaws (D0367) provided on June 6, 2022.  
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary due to a 
fall you suffered. You say the services were an emergency because the dental office was closed. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. Therefore, the coinsurance applied 
to the extraction was processed correctly. The remaining services are not covered under your dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, codes D6010, D5820, and D0367 are 
not among those covered under this benefit. Additionally, you have been asked to pay the difference between 
the out-of-network providers charges and the Plans payment. 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 pay for an 
extraction of an erupted tooth (D7210), surgical placement of an implant (D6010), an interim partial upper 
denture (D5820), and a cone beam computed tomography (CT) scan of both jaws (D0367) provided on June 6, 
2022.