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

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you are having a hard time sleeping and cannot walk properly. The Plan denied your request. The Plan says network providers are available.
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 orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says coverage cannot be approved for this device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has had a stroke and has a pressure ulcer. The record does not indicate that the evaluation was performed by a licensed/certified medical professional with specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs.
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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional speech therapy (ST) visits (92507).

You asked the Plan to pre-approve additional ST visits. You say that the additional ST visits requested are medically necessary. The Plan denied your request. The Plan says the additional ST visits requested do not meet criteria.

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 additional ST 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 enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical 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 additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional speech therapy (ST) visits (92507).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303), side rails (E0305) and low air bariatric mattress (E0277).

You asked the Plan to pre-approve a heavy duty extra wide hospital bed, side rails and low air bariatric mattress. You say that the items are medically necessary. The Plan denied your request. The Plan says the member does not meet the criteria for these items.

The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide hospital bed, side rails and low air bariatric mattress have not been met. Specifically, the documentation indicates the enrollee does not meet the weight requirement for heavy duty equipment. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303), side rails (E0305) and low air bariatric mattress (E0277).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

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 has 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 the treatment of low back pain. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of an abscess-intraoral soft tissue (D7510) provided on July 8, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service provided in this case 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 service provided in this case is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incision and drainage of an abscess-intraoral soft tissue (D7510) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that this provider did your hip replacement surgery. The Plan denied your request. The Plan says the necessary services may be obtained in-network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.

You asked the Plan to pre-approve Xiidra. You say that the enrollee requires medication for the treatment of her eye disease. The Plan denied your request. The Plan says Xiidra to de administered at home is not covered under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra.

Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the boost plus drink (B4160).
You asked the Plan to pre-approve the boost plus drink. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve the boost plus drink (B4160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #12.

You asked the Plan to pre-approve the core buildup. You say that you would like the core buildup on tooth #12 to be redone by another dentist. The Plan denied your request. The Plan says this service exceeds the benefit allowance.

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, you are limited to one of either codes D2950, D2952, or D2954 once per tooth per 60 months. The record shows that you received a core buildup, including any pins when required (D2950) on tooth #12 on February 27, 2021 and your core buildup, including any pins when required (D2950) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #12.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injection services (J0585).

You asked the Plan to pre-approve Botox injection services. You say that the requested Botox injection 
services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
clinical value and effectiveness of Botox in the setting of perioperative management of hernia repair have not 
been demonstrated in the peer-reviewed literature.

The Plan follows Medicare rules. Medicare rules say that Botox injections are subject to the criteria listed 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 Botox injection services. Our reviewer 
says that the requested Botox injection services are not medically reasonable according to Medicare rules. Our 
physician reviewer found the review indicates that the provider is requesting chemodenervation with botulinum 
toxin to the lateral oblique muscles in the peri-operativemanagement preceding the planned abdominal 
wall/hernia repair surgery. The clinical value and effectiveness of Botox in the setting of perioperative 
management of hernia repair have not been demonstrated in the peer-reviewed literature. The review has 
determined that the enrollee does not have a covered indication for Botox according to the LCD criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Botox injection services (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested epidural steroid injection.
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 an epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician reviewer found the record indicates that the enrollee has post herpetic neuralgia. The record indicates cervical spine imaging did not document disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis as a cause for the enrollee's pain. Post herpetic neuralgia is not an enumerated covered diagnosis for the requested procedure. The elements of the coverage criteria are not satisfied. The requested service 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 an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extra batteries for a portable oxygen concentrator.
You asked the Plan to pre-approve extra batteries. You say that you are going to Colombia and require the oxygen concentrator during the flight, but its batteries will not last long enough. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because these are not primarily medical in nature and are not covered for use outside of the United States.
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 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. Therefore, we decided that the Plan does not have to pre-approve extra batteries for a portable oxygen concentrator.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (36415, 81003, 70355, 85730) rendered from March 9, 2021, to April 1, 2021
You asked the Plan to pay for laboratory services. You say that all of the services are related expenses to the same illness that has been previously covered by Medicare. The Plan denied your request. The Plan says that this provider is not a network provider with the Plan. The Plan also says they have also determined that these services are not urgent or emergent, nor were they approved in advance.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There are discrepancies between the information given by you, the enrollee, the documentation from the Plan, and the denial rationale provided by the Plan. You state that these services were approved and have been covered in the past. The Plan's denial notices indicate that an authorization exists for this provider but that the services billed do not match what was authorized. The Plan did not mention this or provide any information about what was approved from this provider or when. The file also includes a notice to you that the Plan agreed to reprocess the claim for the March 9, 2021 date of service; however, the Plan also fails to mention this or explain why this service remains denied as of the time this case was sent to Maximus. Given this information, we find that the Plan has failed to support that you did not have a reasonable belief that the services at issue would be covered. However, the Plan did not submit the authorization. Therefore, we decided that the Plan has to pay for laboratory services (36415, 81003, 70355, 85730) rendered from March 9, 2021, to April 1, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar medial branch block.
You asked the Plan to pre-approve a lumbar medial branch block. You say that the requested lumbar medial branch block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested lumbar medial branch block.
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 lumbar medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested lumbar medial branch block. Our physician reviewer found the enrollee has a history of chronic low back pain due to lumbar spondylosis with radiculopathy, and lumbar facet arthropathy. On physical exam he has a mildly antalgic gait, not widened, no foot drop; No obvious deformities of the lumbar spine; tender to palpation over L4, L5 spinous processes, left paraspinal regions, left L4-5, L5-S1 facets; range of motion moderately decreased in flexion, extension, lateral bending, rotation; sensation intact in anterior thigh (L3), medial leg (L4), lateral leg/dorsum of foot (L5), lateral foot. He has continued to have with low back pain despite prolonged courses of conservative therapy including medical therapy, including opiates, chiropractic therapy, and physical therapy. His provider has requested left L3, L4, L5 medial branch nerve blocks. In this case, the enrollee has radiculopathy. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 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 lumbar medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar medial branch block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult and three clinical crown lengthenings to be provided by a periodontist.

You asked the Plan to pre-approve the consult and clinical crown lengthenings. The Plan denied your request. The Plan says your contract with the Plan only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consult and three clinical crown lengthenings to be provided by a periodontist.