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

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  

You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  

The Plan follows Medicare rules. Medicare rules say that RFA is only covered for two sessions within a 12 month period.  

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 radiofrequency ablation (RFA). Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain with decreased extension range of motion and tenderness over the upper cervical facet joints. The enrollee takes Fiorcet, Gabapentin and Percocet for pain. The enrollee has had 3 separate sessions of cervical RFA. This request exceeds utilization criteria of two sessions in a rolling 12 month period. Therefore, the request is considered not medically reasonable or 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolastin C.  You asked the Plan to pre-approve Prolastin C. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested drug.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Prolastin C. Our reviewer says that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition.  The Medicare approved  drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer found the elements of the coverage criteria are not satisfied.  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 Prolastin C have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolastin C.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (Pembrolizumab), Carboplatin, and Alimta
(Pemetrexed) for the enrollee.
You asked the Plan to pre-approve Keytruda (Pembrolizumab), Carboplatin, and Alimta (Pemetrexed). You say
that this drug treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage
criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda
(Pembrolizumab), Carboplatin, and Alimta (Pemetrexed). Our Physician Reviewer determined that
the requested drug regimen was medically reasonable and necessary for the enrollee in this case.
The Plan argues the records show the enrollee had progression of disease confirmed with imaging, while on
Keytruda and therefore treatment cannot be continued. The Plan argues that, as Keytruda was used as first-line
treatment and failed, Keytruda, Carboplatin, and Alimta cannot be approved as second line treatment, per the
NCCD compendia.
Our Medical Director has concluded the Plan is correct in this case. The National Comprehensive Cancer
Network (NCCN) guidelines state "If progression on PD-1/PD-L1 inhibitor, using a PD-1/PD-L1 inhibitor is
not 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 Keytruda (Pembrolizumab), Carboplatin, and
Alimta (Pemetrexed) have not been met. Therefore, we decided that the Plan does not have to pre-approve
Keytruda (Pembrolizumab), Carboplatin, and Alimta (Pemetrexed) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the total thyroid lobectomy (60220).  

You asked the Plan to pre-approve the total thyroid lobectomy (60220). You say that the policy states a total lobectomy thyroidectomy is covered for a benign nodule and the cytology report states a benign nodule. The Plan denied your request. The Plan says the nodule is biopsy-proven to be benign and is smaller than the 4cm threshold.  

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 total thyroid lobectomy (60220). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation did not demonstrate that the fine needle aspiration was repeated after 2020, nor did it show a >4 cm thyroid nodule or compressive/structural symptoms. The thyroid ultrasound report from November 3, 2021, stated that the left thyroid nodule had increased in size and the right nodule had decreased, but that the size differences compared to past ultrasounds "may be technical." In summary, based on available documentation, the request for the unilateral thyroid lobectomy is not medically reasonable and necessary to manage the patient's condition. 

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 total thyroid lobectomy (60220) have not been met. Therefore, we decided that the Plan does not have to pre-approve the total thyroid lobectomy (60220).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve peripheral angiogram of the left leg.  

You asked the Plan to pre-approve peripheral angiogram of the left leg. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 peripheral angiogram of the left leg. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of peripheral vascular disease and previous right leg angiography/stent placement. While the enrollee has a history of peripheral vascular disease, the left leg has no manifestations of severe arterial insufficiency. Moreover, the ankle brachial index (ABI) is .76 on the right and .93 on the left. There is insufficient documentation to support the medical necessity for left leg angiography 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 peripheral angiogram of the left leg have not been met. Therefore, we decided that the Plan does not have to pre-approve peripheral angiogram of the left leg.
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 does not have a secure airway for transfer to another hospital. She is presently receiving appropriate services in the short-term acute care setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.    

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on December 21, 2020.
You asked the Plan to pay for hearing aids purchased on December 21, 2020. You say that you believe the Plan
should pay $1000 toward these hearing aids. The Plan denied your request. The Plan says the Plan contract you
were a member of in 2020 does not include hearing aid coverage. Maximus overturned the Plans denial stating
the Plan contract sent with the case file included a hearing aid benefit. The Plan requested a reopen and
provided the appropriate contract for your county and zipcode.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare does not
cover hearing aids or related services. The Plan contract you were a member of for the date of service in
question did not provide any supplemental hearing aid coverage. Though hearing aids may be appropriate in
this case, neither Medicare nor the Plan contract you were a member of at that time covered or paid for hearing
aids. Therefore, we decided that the Plan does not have to pay for hearing aids provided on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 24, 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 the provider did not bill as required by Medicare coding regulations.  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 71045 is a column II code to column I code 74022. 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 imaging services provided to the enrollee on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a core buildup (D2950) provided by an out-of-network provider on March 15, 2021.  You asked the Plan to pay for a core buildup. You say that a core buildup is needed when you do the crown. You say that you think that this should be covered. The Plan denied your request. The Plan says D2950 is 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 pay for a core buildup (D2950) provided by an out-of-network provider on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit greatly at the LTACH level of care. The Plan denied your request. The Plan says that records show that the enrollee does not require daily physician management for approximately 25 more days and the enrollee does not require specialized nursing services that are only available in an LTACH.  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. The enrollee was admitted with acute kidney injury in setting of toe infection requiring amputation. The record also indicates that enrollee had coronavirus pneumonia. The record indicates that the enrollee is improving and is still requiring acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.  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 for the enrollee.
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 requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says medical necessity 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 do not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paramedic intercept services provided on April 16, 2021.  You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says no agreement between the advanced life support (ALS) and basic life support (BLS) ambulance providers exists. The Plan also says that since no contract exists between the ALS and BLS providers, you are responsible for the full billed amount of the ALS paramedic intercept that was provided.    The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. The Plan has confirmed that this paramedic was not under contract with the ambulance company. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on April 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).  You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been satisfied.  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 Gelsyn-3. Our reviewer says that the requested drug is not medically reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. In this case, the Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. The case file does not contain documentation of trial and failure of Orthovisc or Supartz FX. In addition, the documentation does not support that Orthovisc or Supartz FX would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the transport chair (E1038) and sales tax (S9999) provided on February 13, 2021.  You asked the Plan to reimburse you for the transport chair and sales tax. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the transport chair (E1038) and sales tax (S9999) provided on February 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 outpatient occupational therapy (OT) visits.  

You asked the Plan to pre-approve occupational therapy visits. You say that you had surgery on your foot and was not able to finish your rehabilitation previously. The Plan denied your request. The Plan says the requested services 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 occupational 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 the documentation does not indicate that the requested therapy is generally accepted as specific and effective therapy for your condition. The reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The reviewer also found that the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy visits have not been met. Specifically, the file does not show that the requested therapy is generally accepted as specific and effective therapy for your condition. Therefore, we decided that the Plan does not have to pre-approve 10 outpatient occupational therapy (OT) visits.