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

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the Intracept procedure. You say that the patient has failed non-operative treatment and the pain is disabling which affects quality of life. You say that the evidence clearly supports the Intracept procedure as the primary treatment for chronic low back pain and the denial should be overturned. The Plan denied your request. The Plan says services that are not medically necessary are not covered.  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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for low back pain and more research is needed.     
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the requested bed. You say that the enrollee will require body positioning to
alleviate pain. The Plan denied your request. The Plan says the enrollee does not require frequent changes in
body positions.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed is only covered under
certain medical indications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested bed. Our physician
reviewer found that the enrollee has a torn hamstrings in her left leg, osteoarthritis in right knee, with plans for
left proximal hip surgery and right knee. A request for a semi-electric hospital bed was made as she will require
frequent position changes due to pain following surgery. It is estimated that she will need it for 6 weeks. The
enrollee's condition does not require position of the body in ways not feasible in an ordinary bed, based on the
expected surgery and recovery. It was not clearly documented that she would require frequent changes in body
position or that there would be a need for immediate changes in body position. It was not clearly documented
that her condition will require special attachments that cannot be fixed and used on an ordinary bed. Therefore,
a semi-electric hospital bed is not medically necessary for this enrollee based on the provided 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 the requested bed have not been met. Therefore, we decided that the Plan does
not have to pre-approve a semi-electric hospital bed.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the documentation supports the need for a skilled nursing facility. The Plan denied your request. The Plan says the member can receive care in a lower-level setting.
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 skilled nursing services are not required, and daily skilled therapy services are not required. Our reviewer found that a lower level of care is more appropriate. 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says The Plan says the records are insufficient to support payment for these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan
denied your request. The Plan says the enrollee must either have a history of osteoporotic fracture or has tried
and failed Zoledronic acid.
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 Prolia. Our reviewer says that the Plan's
step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of drug
Zoledronic acid first before they will approve the requested drug. In this case, the enrollee has not tried and
failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s)
would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 17, 2021.
You asked the Plan to pay for procedure code 70450. You say that these services were performed in two different sessions. The Plan denied your request. The Plan says this code is bundled into another code billed on the same date of service.
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 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 procedure code 70450 billed for date of service July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve partial prosthetic fingers for left digits 2, 3, and 4 requested under
code L7499.
You asked the Plan to pre-approve the partial prosthetic fingers. You say that this request was submitted with
the correct codes for the items that are needed by the enrollee. The Plan denied your request. The Plan says that
the Plan denied this as it was coded incorrectly but did not review its initial denial within the allowed time
frame.
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 failed to issue a timely decision for this appeal. It is noted by the
provider that the coding was at issue in the denial and that the Plan believed L6020 was the correct code for the
requested prosthetics. However, the Plan did not indicate this argument in its submission to Maximus. No valid
citations were submitted to support that the denial of these items was correct. Review of the code definitions
does confirm that code L6020 would not apply to the requested partial finger prosthetics. Without a valid
rationale, we find that the denial of the requested is not supported. Therefore, we decided that the Plan has to
pre-approve partial prosthetic fingers for left digits 2, 3, and 4 requested under code L7499.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sliding transfer bench for the enrollee.
You asked the Plan to pre-approve a sliding transfer bench. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested item is not consistent with the definition of durable medical equipment as presumptively medical or generally not useful to a person in the absence of an illness of injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a sliding transfer bench for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 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 physician 
reviewer found that you were admitted to the acute care hospital with pneumonia and acute respiratory failure. 
Recent notes describe you tolerating weaning trials and is off vasopressors. You appear to be improving and 
should only require short-term additional acute care services that may be continued safely at the current facility 
for now. You do not require services at the LTACH that are not already available at the current facility. 
Transfer to LTACH is not medically necessary as it would not be clinically advantageous.
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria.
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 the enrollee is receiving appropriate care at the present acute care hospital. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan.
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 long term acute care hospital (LTACH) services.
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 requested admission to an IRF does not meet 
criteria.
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a female catheter and surgical dressing.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The file shows that a PureWick female external catheter was requested. The item at issue in this appeal does
not serve a purpose that is primarily medical in nature. This item is available to the general public and would be
helpful even to those who are not sick or injured.
The file shows that Mepilex Border sacrum wound care dressing was requested. The records do not show that
the enrollee has a moderately to highly exudative full thickness wound. Based on this information, we decided
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to
pre-approve a female catheter and surgical dressing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of cranial neurostimulator
pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays (CPT
code 61886).
You asked the Plan to pre-approve the service. You say that you have documentation from neuropsychiatric
evaluation which states you have cognitive impairment and are not a candidate for deep brain stimulation. The
Plan denied your request. The Plan says you have documentation from Neuropsychiatric evaluation which
states you have cognitive impairment and are not a candidate for deep brain stimulation.
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 service. Our physician reviewer
found you neuropsychological evaluation concluded that the placement of DBS could lead to worsening of
your cognitive impairment. Your cognitive status could also interfere with your ability to benefit. This would
therefore be an exclusion to coverage of DBS and this service would not be reasonable and 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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or
inductive coupling; with connection to 2 or more electrode arrays (CPT code 61886).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lower extremity for the
enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says that a different study should show all the detail that the doctor needs.
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 the MRI. Our reviewer says that the
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has had
extensive workup and the likely diagnosis is CRPS, for which no classic imaging criteria are available. As part
of the workup, the MRI of the lower extremity has been requested. Based upon your extensive workup, which
has been negative MRI of the right lower extremity would allow for evaluation of boney as well as soft tissue
abnormality, and at this point, seems to be a reasonable test.
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
magnetic resonance imaging (MRI) of the lower extremity for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Caris molecular intelligence profile (MI).
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found Caris Molecular Intelligence has not been approved by the United States Food and Drug Administration. The review indicates that the Caris molecular intelligence (MI) profile is experimental and investigational because of insufficient evidence of its effectiveness. The review has determined that the requested item is 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 the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the Caris molecular intelligence profile (MI
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 16, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator.  You asked the Plan to pre-approve the Inogen portable oxygen concentrator. You say that the Inogen portable oxygen concentrator is necessary for you to leave the home and have more freedom. The Plan denied your request. The Plan says you have stationary equipment in your home, and this would be duplicate equipment.   The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules stated duplicate equipment is not covered. This item was requested for use outside of the home and is duplicate to equipment you already have. Although this item may be helpful, neither Medicare nor the Plan covers equipment. Therefore, we decided that the Plan does not have to pre-approve the Inogen portable oxygen concentrator.