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

We decided that the Plan does not have to pay for the services (81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317, 81401) provided on April 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these codes are not separately payable.
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 codes 81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317, and 81401, are column II codes to column I code 81445. 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 the services (81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317, 81401) provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma (PRP) injections provided on June 29, 2021.
You asked the Plan to pay for the PRP injections. You say that this has been covered in the past. You say that these services should be covered at 80%. You also say that these services save you from having an expensive surgery. The Plan denied your request. The Plan says the platelet rich plasma (PRP) injection is not covered by Medicare.
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 pay for the PRP injections. Our reviewer says that the PRP injections are not considered medically reasonable and necessary in this case.
Our physician reviewer found the provided documentation does not have sufficient evidence to support the use of PRP injections for the enrollee's condition at this time. Therefore, this request for PRP injections is considered 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 the PRP injections have not been met. Specifically, the provided documentation does not have sufficient information to support the use of PRP injections. Therefore, we decided that the Plan does not have to pay for the platelet rich plasma (PRP) injections provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pre-approve Mitomycin, Capecitabine, and Dexamethasone for the
enrollee.
You asked the Plan to pre-approve this drug combination. You say that this drug regimen 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. At issue is coverage for Mitomycin, Capecitabine, and
Dexamethasone for the treatment of metastatic colon cancer. The Maximus Physician Reviewer determined
that, although Mitomycin, Capecitabine, and Dexamethasone are not approved by the federal drug
administration (FDA) for the enrollee's condition, their use is supported by one of the major drug compendia or
by clinical research that appears in a CMS-approved medical journal. This documentation supports that the
requested drugs are safe and effective and otherwise reasonable and necessary for this enrollee. The Plan
argues there is no established evidence to support the use of mitomycin along with capecitabine and
dexamethasone as subsequent salvage treatment for metastatic colon cancer after multiple lines of prior
chemotherapy.
The medical records show the enrollee has a diagnosis of metastatic colon carcinoma with multiple liver
lesions and pulmonary nodules. The enrollee has been treated with palliative chemotherapy. Salvage
chemotherapy with panitumumab and capecitabine was started in February 2021. On May 25, 2021treatment
was to begin soon with "5-FU" and mitomycin. The plan is correct in this case. A citation in NCCN states that
the panel recommends against the use of mitomycin (and others) either as single agents or in combination, as
therapy in patients exhibiting progression of colon cancer after treatment with standard therapies. The
documentation does not support that the requested drug is safe and effective and otherwise reasonable and
necessary 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 this drug combination have not been met. Therefore, we decided that the Plan
does not have to pre-approve Mitomycin, Capecitabine, and Dexamethasone for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you are not able to go back home alone. You 
say that you are under kidney dialysis three times a week and cannot walk, stand up, or go to the bathroom by 
yourself. You say that you need help to recover and gain strength. The Plan denied your request. The Plan says 
the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met 
at an alternate level of care. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and clear lungs. The enrollee received physical therapy and occupational 
therapy. The enrollee was at a moderate to maximal assist level with bed mobility. He required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity 
of illness or intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on April 25, 2021.
You asked the Plan to pay for the transportation services. You say that the non-emergency ambulance transports were medically necessary. The Plan denied your request. The Plan says the non-emergent ambulance transportation was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 the transportation services. Our reviewer
says that the non-emergency ambulance services are not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for the enrollee on April 25, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on April 25, 2021. The reviewer found that the documentation does not support that the ambulance transport on April 25, 2021 was medically reasonable and necessary 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 the transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and ground mileage (A0425) provided on April 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested device is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested device is experimental/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 a MyoPro orthosis. Our reviewer says that the requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on March 20, 2020.
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says one unit of 99214 was paid but the second unit is a duplicate and not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that claims that have been determined to be exact duplicates of another claim are denied. We looked at the file and Medicare rules. In this case, the records submitted verify that one office visit was performed. The second billing of 99214 is a duplicate in this case. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on April 13, 
2021. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were not aware you would be charged 
for this service. The Plan denied your request. The Plan says the benefit for an annual wellness visit has been 
exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on 
April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on April 27, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
these services were medically necessary. The Plan denied your request. The Plan says these services do not 
meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical 
Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician 
about the provided services and document the consent or declination date to consultations and date of the 
consultations in the patient's medical record. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not document that the 
member's primary care physician was consulted. Additionally, there is not a referring physician on the claim. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on 
April 27, 2021.
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 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 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Ongoing, daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided 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 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: 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical management of a hip fracture after a fall. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
You asked the Plan to pre-approve RFA to the SI joint. You say that the requested injection services are medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature.
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 RFA to the SI joint. Our reviewer says that the requested RFA services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee uses ice, rest, and NSAIDs for pain relief. The enrollee has had prior RFA of the SI joint in 2017 and 2018 with long lasting pain relief. The requested treatment is considered experimental/investigational because of the wide variation in effectiveness reported in the literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty.
You asked the Plan to pre-approve total knee arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve total knee arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for the right knee post the unicompartmental replacement. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology (in such a clinical setting.) There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for total knee arthroplasty (27487) is not medically reasonable or 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 total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the second emergency ambulance transport (A0429,
A0425) billed on April 26, 2021.
You asked the Plan to waive the copayment for the second ambulance transport. You say that you should only
have one copayment for ambulance services on this date, as you rode in one ambulance. The Plan denied your
request. The Plan says that you are responsible for a $300 copayment for each one-way trip by ambulance.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $300 copayment for each one-way trip by ground or air
ambulance.
The Plan says you must pay a $300 copayment for the second ambulance transport. Based on the Plan contract,
you may be billed a $300 copayment for each one-way ambulance trip. The Plan was billed for two ambulance
trips and has assessed two copayments. However, documentation was not provided to support that the second
provider actually provided transportation or had any contact with you. The provided medical records are
insufficient to support the second ambulance service as billed. Therefore, we decided that the Plan has to waive
the copayment for the second emergency ambulance transport (A0429, A0425) billed on April 26, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic low back pain and degenerative disc disease of the lumbar spine have not been 
demonstrated in the peer-reviewed literature. 
 
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 requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental for low back pain. More research is needed to show safety and efficacy. Our 
physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.