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

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78814)
provided on March 15, 2021.

You asked the Plan to pay for a PET scan. You say that this was billed with a valid diagnosis. The Plan denied
your request. The Plan says the diagnosis does not support this service.

The Plan must follow Medicare rules. Medicare rules say that uses of FDG PET for patients with a presumptive
diagnosis of dementia-causing neurodegenerative disease (e.g., possible or probable Alzheimer's disease,
clinically typical Frontotemporal dementia, dementia of Lewy bodies, or Creutzfeldt-Jacob disease) are
nationally non-covered. Therefore, we decided that the Plan does have to pay for a positron emission
tomography (PET) scan (78814) provided on March 15, 2021.

We looked at the file and Medicare rules. This service was billed with a diagnosis that is considered a
neurodegenerative disease, which is a nationally non-covered indication for a PET scan. Based on this
information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we
decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78814) provided on
March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
March 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 
31, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 home health skilled nursing visits.

You asked the Plan to pre-approve 18 home health skilled nursing visits. 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 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 18 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on review of the available records, and based on the condition of your wound, you do not meet CMS/LCD coverage criteria for Home Health services with nursing for additional visits to continue. Your care needs have changed based on the status of the wound and per the recommendation of the wound care nurse, you need to be at a higher level of care as in an inpatient skilled nursing facility (SNF) setting with daily skilled nursing 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 18 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care for the elective total knee 
arthroplasty (CPT code 27447-RT). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is necessary. The Plan 
denied your request. The Plan says you are medically stable and has been provided medical clearance to 
undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27447 is not 
listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the 
procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation 
provided to support the expectation you will require a greater than 2 midnight stay. The Plan states if you 
experience any peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed on concurrent review with updated clinical information. 

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the record does not show that the admitting physician 
reasonably expects that your necessary hospital care will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care for the elective total knee arthroplasty (CPT code 
27447-RT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee o October 20, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for genetic testing. Maximus overturned the
Plans decision stating the Plan did not clearly explain their denial. The Plan requested a reopen and provided
additional information. The Plan stated that the provider is out of network and this type of testing requires prior
authorization both in and out of network.

The Plan is correct in this case. Medicare allows Plans to require prior authorization. The contract with the Plan
says that genetic testing requires prior authorization. The records provided do not show the enrollee had prior
authorization for this testing. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee o October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus Anser ADA diagnostic testing provided on September 8, 2020.
You asked the Plan to pay for the Anser ADA testing. You say that this is a test which provides information about the serum concentrations of adalimumab. This provides useful information to the provider which can be used to guide treatment decisions. The Plan denied your request. The Plan says this unlisted code was not billed with the required identifying information and cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that MDTs, such as the Anser ADA assay, may only be covered when they are reviewed by the MolDX contractor and assigned a unique identifier. The DEX Diagnostic Exchange does not include information regarding the status of this test. This indicates that the test was not reviewed or approved through the MolDX technical assessment process. As such, this test is not payable at this time. Therefore, we decided that the Plan does not have to pay for the Prometheus Anser ADA diagnostic testing provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408) provided on February 11, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408) provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion-G orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the MyoPro would immediately restore the enrollee's arm function and range of motion by allowing the enrollee to control motors. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the MyoPro 2 Motion-G orthotic device at issue in this case meets Medicare criteria for medically reasonable and necessary. Current guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 Motion-G orthotic device (CPT code L8702), for the enrollee.
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 a LTACH admission is medically 
necessary as the member lives alone and cannot be left alone and is in and out of the hospital. The Plan denied 
your request. The Plan says based on Medicare guidelines, the LTACH services do not meet the requirements 
for approval. 
 
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 that the enrollee was admitted to the acute care hospital on September 6, 2021 with 
respiratory failure due to chronic obstructive pulmonary disease (COPD) exacerbation. On October 5, 2021 the 
enrollee was on 4 liters of oxygen via nasal cannula with an oxygen consumption saturation of 100%. His 
respiratory rate was 18 per minute. Long term acute care hospitals (LTACHs) are certified as acute care 
hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of 
short-term acute care hospitals.

The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation 
does not support that the enrollee in this case requires services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. The documentation does not support that an additional 25 
days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more specialized therapy because you are 
having difficulty walking and your legs are weak. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that you require the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Care in the home or an assisted living facility with home health services or in a nursing 
facility with part time services appears to be appropriate in this case.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says goals appear to have 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5214).
You asked the Plan to pre-approve the dental services. You say that although there is a paid claim for dental code D5214 in 2019, you are not sure who the doctor on the claim is nor were you given dentures at any time during 2019. The Plan denied your request. The Plan says the dentist's office stated they recall you came in asking the dentist to refit the dentures they provided you in 2019 because they were bothering you.
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. The plans records indicate that you previously received dental service D5214 on February 26, 2019. Therefore, you have exhausted your covered benefits for the 2021 calendar year. Therefore, we decided that the Plan does
not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (CPT code D5214).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the auricular stimulator.
You asked the Plan to pre-approve the auricular stimulator. You say that the service is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the auricular stimulator have not been met. Medicare does not cover electrical devices are non-covered by Medicare as electrical acupuncture. Therefore, we decided that the Plan does not have to pre-approve the auricular stimulator
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pancreatectomy (CPT code 48150) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the services. You say that the tumor is cancerous, and the diagnosis code must be a mistake. The Plan denied your request. The Plan says they called the out-of-network provider and confirmed that they have not seen you before and therefore, you are not in a current treatment plan. The Health Plan confirmed that an in-network provider can provide the service and has available appointments within the month and is within the Medicare allowable distance and time; therefore, the Health Plan does not have a network deficiency.

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 the pancreatectomy (CPT code 48150) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the health plan's denial should be upheld. The enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of 
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRF admission and services.
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 a LTACH admission is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet all the requirements.
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 that the enrollee was admitted to the acute care hospital on August 6, 2021 with respiratory failure due to Coronavirus (COVID-19) infection, as well as rapid atrial fibrillation. Intubation and mechanical ventilation were required. A tracheostomy and a PEG tube have been placed. A chest tube was placed for a pneumothorax. On October 4, 2021 the enrollee was agitated, restless and confused. Spontaneous breathing trials were to continue as tolerated. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have
not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.