Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010 x 2), implant surgery (D6011 x 2), bone graft per site (D6104 x 2), and guided tissue regeneration (D4266).
You asked the Plan to pre-approve the dental services. You say that if you do not get these implants, you will suffer lots of pain when you eat. You also say that the services are medically necessary. The Plan denied your request. The Plan says dental implants and associated services are excluded from coverage.
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 implants and related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010 x 2), implant surgery (D6011 x 2), bone graft per site (D6104 x 2), and guided tissue regeneration (D4266).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypercoaguable work up.
You asked the Plan to pre-approve the genetic testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210G>A (G20210A) variant in the F2 gene, and the MTHFR gene which encodes the 5,10-methylenetetrahydrofolate reductase enzyme is non-covered. We looked at the file and Medicare rules. Per LCD L36159, the requested testing is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a hypercoaguable work up.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that you have BPH and constant leaking with incontinence. These supplies will keep up with hygiene and prevent skin breakdown. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan for the enrollee.

You asked the Plan to pre-approve a CT scan. You say that a CT scan is medically necessary. The Plan denied your request. The Plan says insufficient medical records were submitted regarding the length of the enrollee's smoking history.

The Plan must follow Medicare rules. Medicare rules say that low dose CT scans are covered only when the enrollee has a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes) and the medical records must be appropriately documented and must contain documentation of the actual "pack - year smoking history (number);" as well as current smoking status, and for former smokers, the number of years since quitting smoking. The medical records provided do not contain all the information required for approval of this service. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) to be
provided a periodontist.
You asked the Plan to pre-approve the dental service. You say that your dentist advised that you need a deep
cleaning. The Plan denied your request. The Plan says dental services must be provided by a participating
general dentist. The Plan also says that services performed by a periodontist are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
comprehensive oral evaluation (D0150) to be provided a periodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on July 26, 2021, billed with codes G0463 and 93000.
You asked the Plan to pay for the outpatient hospital services as billed. You say that this claim should be paid. The Plan denied your request. The Plan says since code 93000 has a status indicator of "M", this claim cannot be paid until this error is corrected.
The Plan must follow Medicare rules. Medicare rules say that all outpatient hospital claims must be processed through the I/OCE. This applies edits which have various effects on claim processing/payment. In this case, per the Integrated OCE (IOCE) Specifications V22.2, OCE edit 72 is invoked when a code is billed with status indicator "M". This indicator means that the codes is not billable to the contractor on outpatient hospital claims. Code 93000 has a status indicator of "M". This edit requires the claim to be returned to provider, meaning that no payment is made until this edit is corrected. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on July 26, 2021, billed with codes G0463 and 93000.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Gelsyn-3. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Orthovisc or Supartz FX before they will approve the requested drug, Gelsyn-3. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gelsyn-3 (J7328).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (CPT code J7323), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step
therapy (multi-injection) device(s): Orthovisc OR Supartz FX. The Plan states there is no indication the Plan's preferred agent(s) would likely be: less effective, and/or cause adverse effects for the enrollee.

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 the medication. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 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 the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (CPT code J7323), for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for continued SNF services after January 16, 2022.
You asked the Plan to pay for SNF care. You say that the enrollee needs therapy to gain strength. The Plan denied your request. The Plan says that the enrollee no longer meets the health condition to stay there.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 16, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued skilled nursing facility (SNF) services after January 16, 2022.
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 oxygen equipment purchased on July 5, 2021.
You asked the Plan to pre-approve the services. You say that the claim should be reviewed. The Plan denied your request. The Plan says this expense is covered.
The Plan must follow Medicare rules. Medicare rules say that oxygen equipment is only covered as a rental. The file shows that this equipment was purchased, not rented. Based on this information, we decided that Medicare rules for coverage of the serivces have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen equipment purchased on July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA and PTEN testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered when specific criteria are met and PTEN testing is covered when 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a family history of a
mother with ovarian cancer. The mother was BRCA-negative. The enrollee has a personal history of herpes
simplex virus and fibrocystic breasts. The enrollee does not have a personal history of breast, ovarian, or
pancreatic cancer. In addition, there is not documentation of a family history of a known deleterious BRCA1 or
BRCA2 gene mutation. The BRCA testing is not reasonable or medically necessary. There is no documentation
that PTEN testing is reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve BRCA and PTEN testing.
Local Coverage Determination (LCD) L35000 referenced by the Plan is not valid for the state of California and
was not used in the Maximus determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator is necessary for the enrollee to allow him to get out of the house. The Plan denied your request. The Plan says a portable oxygen concentrator is not covered outside of the home. The Plan states the enrollee currently has equipment for home use provided by the Plan.

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. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. This equipment also services the same purpose as equipment the enrollee already has present for use in the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apicoectomy (D3421) and bone graft in conjunction with periradicular surgery (D3428) for tooth # 13.
You asked the Plan to pre-approve the dental services. You say that your doctor advised there is an infection under your root canal. You say that you have not exhausted your dental benefits for the year. You also say that these services should be approved. The Plan denied your request. The Plan says apicoectomy is not listed as a covered service. The Plan says that bone graft in conjunction with periradicular surgery is not listed as a covered service either.
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 apicoectomy and bone graft in conjunction with periradicular surgery are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve apicoectomy (D3421) and bone graft in conjunction with periradicular surgery (D3428) for tooth # 13.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for a diagnostic mammogram. We decided that the Plan does not have to reduce the copayment for a diagnostic mammogram to the amount you requested.
You asked the Plan to reduce the copayment for a diagnostic mammogram. You say that you disagree with the charges and feel that the mammogram should be considered a screening. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to reduce the copayment for a diagnostic mammogram from $35 to $10.
The Plan says that you must pay a $35 copayment for a diagnostic mammogram. However, you cannot be asked to pay more than a $10 copayment for outpatient diagnostic tests. Therefore, we decided that the Plan has to reduce the copayment for a diagnostic mammogram from $35 to $10.
We also decided that the Plan does not have to waive the $10 copayment for a diagnostic mammogram.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic procedures and tests.
The medical records show that you received a diagnostic mammogram on September 10, 2021. Therefore, You are responsible to pay the $10 copayment. We decided that the Plan does not have to waive the $10 copayment for a diagnostic mammogram.
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 vehicle hitch/lift to transport a wheelchair.
You asked the Plan to pre-approve a vehicle hitch/lift. You say that a vehicle hitch/lift is needed to carry your
wheelchair. The Plan denied your request. The Plan says a vehicle hitch/lift is not covered by Medicare because
it is not used in the home.
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. Equipment to transport your wheelchair is not covered by Medicare.
Therefore, we decided that the Plan does not have to pre-approve a vehicle hitch/lift to transport a wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that you have some concerns as to what might have happened during surgery that made the outcome not as good as it was when you had the other leg done eleven years ago by another surgeon. You also say that because this provider did the operation, you believe that the doctor who did the previous operation is the only one who can address your concerns with firsthand knowledge and give you a knowledgeable answer to your concerns and any other surgeon would be guessing because they were not there. The Plan denied your request. The Plan says the request for an office visit this surgeon is not for an emergency visit. The Plan says that you were redirected to an equally qualified in-network provider.

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 a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional home health physical therapy visits.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have had 16 PT visits and have been approved for four additional visits. The notes dated December 31, 2021 state you are amble to ambulate 175 feet with a walker and can go up and down a flight of stairs with assistance. There are no other records provided for review. The documentation does not support that eight further PT visits are reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional home health physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second level laminectomy.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found magnetic resonance imaging (MRI)
show stenosis at only the L3-4 level for this enrollee. Only one level laminectomy is required. A second level
procedure is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a second level laminectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer device.

You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is 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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The
record indicates that the enrollee has had decompression and fusion at L3-4, the level requested for treatment.
The record indicates that the enrollee has a body mass index of 41. The elements of the coverage criteria are
not satisfied.

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 the Vertiflex interspinous spacer device.