Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastopexy.

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 the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has excessive breast skin that is causing intertrigo. The records also indicate she is having liposuction of the thigh and recently had brachioplasty. There is no documentation of trial and failure of conservative treatments. The records do not support that the mastopexy is reasonable or medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastopexy.

The Plan references Local Coverage Determination (LCD) L34698 in their determination; however, this LCD is not valid for Part B Medicare and was not used in the Maximus determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beyond
September 10, 2021.
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 the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 not medically necessary. Our physician reviewer found the enrollee was
admitted to the hospital on July 12, 2021 with Bipolar type schizoaffective disorder. Based on the submitted
records, it is not expected that she will improve in a reasonable period of time for the dates in question, as she
does not have suicidal or homicidal ideation and denies auditory and visual hallucinations. She does not have
dangerousness to self or others and is compliant with treatment. She has unchanged continual delusional
content. It does not appear that active treatment is taking place. The continued services are therefore not
reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve continued inpatient psychiatric services beyond September 10, 2021.
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 she needs physical therapy for chronic left lumbar radiculopathy. The Plan denied your request. The Plan says additional visits 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 that the patient has had prior therapy and can transition to a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met as there is no evidence of treatment with insulin injections.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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. The Plan denied your request. The Plan says you do not require physician oversight, or an intensive team for 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 physician reviewer found that you were admitted to the acute care hospital for a stroke. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing and evaluation (96132).

You asked the Plan to pre-approve neuropsychological testing and evaluation. You say that the medical records
provided support the necessity of the services. The Plan denied your request. The Plan says the services
requested were 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 neuropsychological testing and
evaluation. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found it was noted that this enrollee's provider is asking for an
excessive amount of the procedure beyond which is approved by LCD L33632. This enrollee has not been
evaluated for depression or organic brain syndrome utilizing the Mini Mental Status Exam or the Beck
Depression scale. Based on review the records provided in the information provided this enrollee does not meet
the criteria for neuropsychological testing beyond which is approved by LCD L33632 based on the enrollee's
clinical history and documentation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of neuropsychological testing and evaluation have not been met. Therefore, we
decided that the Plan does not have to pre-approve neuropsychological testing and evaluation (96132).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for hospitalization and anesthesia for dental
services.

You asked the Plan to pre-approve coverage for hospitalization and anesthesia for dental services. You say that
you feel these services should be overturned. The Plan denied your request. The Plan says the requested
services are not a covered benefit.

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 pre-approve
coverage for hospitalization and anesthesia for dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on April 29, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician.

We looked at the file and Medicare rules. The file shows that the Plan paid for an office visit for the same date
of service at issue for a provider in the same group practice and specialty as the physician for the services at
issue. The services at issue are not separately payable. Therefore, we decided that the Plan does not have to pay
for the office visit rendered on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for ketamine IV infusion provided on May 26, 2020, and July 7,
2020.
You asked the Plan to pay for ketamine IV infusion (99499). You say that continuing with the infusions is
necessary to maintain the control of symptoms. The Plan denied your request. The Plan says ketamine injection
is investigational and not proven reasonable or medically necessary.
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.
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 ketamine IV infusion (99499). Our reviewer
says that the use of this procedure is considered off label. Our physician reviewer found based on review the
records and the literature provided by the manufacturer, this procedure utilizing IV ketamine is not indicated by
the FDA for the treatment of depressive disorders. Based on review of the records provided and the literature
provided on the use of this procedure, it does not appear that this procedure is considered medically necessary
for the treatment of depressive disorder and is not considered in my opinion within the treatment medical
necessity due to no FDA indication and would be considered experimental/not 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 ketamine IV infusion (99499) have not been met. Therefore, we decided that the
Plan does not have to pay for ketamine IV infusion provided on May 26, 2020, and July 7, 2020.
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 care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and is ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sling procedure (57288).
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found appropriate diagnostic testing has not been performed documenting stress urinary incontinence including demonstration of stress incontinence by cough stress test, and urodynamic testing. There is no measurement of post void residual. Also, there is no documentation of conservative management with bladder neck support prosthesis (pessary), urethral inserts, bladder training, or pelvic floor exercise therapy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Sling procedure (57288).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cystourethroscopy with insertion of transprostatic
implant.

You asked the Plan to pre-approve cystourethroscopy, with insertion of transprostatic implant; 4 or more
implants (C9740) and prosthetic implant (L8699). You say that this procedure is indicated for the enrollee's
medical issue. The Plan denied your request. The Plan says this procedure and device is not covered under
Medicare as it is not considered to be 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 looked at the file and Medicare rules. The procedure and implant are not covered by Medicare. Therefore,
we decided that the Plan does not have to pre-approve cystourethroscopy with insertion of transprostatic
implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).

You asked the Plan to pre-approve Gel-One. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gel-One. Our reviewer says that the requested drug is not medically necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gel-One is not approved as step criteria have not 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care.
You asked the Plan to pre-approve home visit for assistance with activities of daily living and personal care (99509). You say that the enrollee is unable to perform assisted daily living tasks. The Plan denied your request. The Plan says help with personal care is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home visit for assistance with activities of daily living and personal care (99509) have not been met. Therefore, we decided that the Plan does not have to pre-approve custodial care
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.
You asked the Plan to pre-approve blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823). You say that the documents demonstrate some obstruction with upper gaze regarding the eyelids. The Plan denied your request. The Plan says very little clinical information was received about the enrollee's illness.
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 blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided record indicates that the enrollee is undergoing elective facial rejuvenation. The records do not indicate an MRD of 2.0 mm less. The records provided do not satisfy the elements of the coverage criteria. 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 blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823) have not been met. Therefore, we decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.