Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased from
Inogen on April 19, 2018.
You asked the Plan to reimburse you for the Inogen One portable oxygen concentrator. You say that portable
oxygen concentrators are covered by Medicare. The Plan denied your request. The Plan says only rented
oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for
coverage.
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare.
Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator
have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen
concentrator purchased from Inogen on April 19, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management
services (99239) provided on January 11, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted
discharge summary does not support hospital discharge day management of more than 30 minutes was
performed.
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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than
30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate
that more than 30 minutes of hospital discharge day management services were rendered. Based on this
information, we decided that Medicare rules for coverage of the hospital discharge day management services
have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of
hospital discharge day management services (99239) provided on January 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 24, 2019 by an out of network provider.You asked the Plan to pay forradiology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on April 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medical Alarm Device (A9280). You asked the Plan to pre-approve the medical alarm device. You say that the enrollee is a fall risk and the medical alarm pendant is medically necessary.The Plan denied your request. The Plan says the item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a Medical Alarm Device (A9280).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with procedure code 99204 provided on September 3, 2019.You asked the Plan to pay for office visit. You say that this visit does qualify for a "new" patient visit and is payable.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this enrollee received service from the same physician group practice and same physician specialty within the previous 3 years and therefore this visit is not payable as a new patient visit.The Plan must follow Medicare rules. Medicare rules say that, for the purposes of evaluation and management visit coding, a new patient is a patient who has not received any professional service from the physician or physician group practice (same physician specialty) within the previous 3 years. We looked at the file and Medicare rules. This enrollee has received a professional service from this physician group practice with the same physician specialty within the previous 3 years, therefore the billing of a new patient visit is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of office visit have not been met.Therefore, we decided that the Plan does not have to pay for an office visit with procedure code 99204 provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 5, 2019 by out of
network provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary and you
would like this claim reprocessed for payment. The Plan denied your request. The Plan says no prior
authorization was obtained; therefore, the claim in question has been correctly denied for payment.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 5, 2019 by
out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for office services and a transthoracic echocardiography (TTE) test provided by Health Care from June 14, 2019 to June 24, 2019.You asked the Plan to waive the cost-sharing for office services and TTE test. You say that you were not told that this provider was out-of-network, and you are on a fixed income.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.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 $490 deductible and 50% coinsurance for out-of-network physician services and 30% coinsurance for out-of-network TTE. At the time these claims were processed, $0 of the $490 combined deductible amount had been met. Your total cost-sharing obligation is therefore $543.41, which meets the $490 combined deductible amount for 2019.You have been asked to pay $490 deductible and 50% coinsurance for office services and30% coinsurance for TTE test. Office services and TTE test fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. This means that you have been asked to pay the correct amountbased on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost-sharing for office services and a transthoracic echocardiography (TTE) test provided by Health Care from June 14, 2019 to June 24, 2019.Your complaint regarding not being told about this provider's network status is considered to be a grievance. MAXIMUS does not have the jurisdiction to address grievances. Please contact the health plan for more information about your grievance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 21, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says based on the documentation provided, medical necessity for inpatient admission has not been established. Therefore, coverage criteria has not been met.
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 based on the clinical records provided, the participant's condition was medically stable. The enrollee was hemodynamically stable throughout observation period.
Her condition stabilized and improved and she was discharged home May 22, 2019 with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department (ED) and/or observation care) would 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 provided on May 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says there is no clear acute diagnosis, so SNF would be appropriate.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem for the enrollee.
You asked the Plan to pre-approve Zolpidem. You say that Zolpidem has been very effective for the enrollee. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Zolpidem for the enrollee.
Benefits for Zolpidem 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch blocks.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee had ineffective response to previous injections.The Plan follows Medicare rules. Medicare rules say that lumbar injections are only covered under certain medical indications.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 requested services. Our physician reviewer found that the enrollee has chronic back pain due to spondylosis with radiculopathy, lumbosacral region. It is documented that the enrollee has constant pain in the low back that radiates to the right leg,and the has persistent low back pain with occasional radicular symptoms down to his left buttock area.The enrollee has been on a pain medication regimen consisting of opiates, Lyrica, and NSAIDs. The enrollee underwent bilateral L4-5 L5-S1 facet joint injections/medial branch blocks (MBBs) on September 30, 2019, with 40% relief for 2-3 weeks.Based on the enrollee's documented radiculopathy, the requested procedure is not medically reasonable and 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess. You asked the Plan to pre-approve Linzess. You say that despite previous medication trials and dietary changes, the enrollee's symptoms continue to persist.The Plan denied your request. The Plan says Linzess to be taken 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 Linzess. Benefits for Linzess may be available under Medicare Part D.Contac tthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approved examethasone. 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 self-administered drugs are not a covered 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-approved examethasone.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imlygic for the enrollee. You asked the Plan to pre-approve Imlygic. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that your request does not meet the Medicare rules because there is no support in the compendia or current literature for Imlygic (T-VEC) and Keytruda to treat advanced melanoma. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Imlygic. Our reviewer says that Imlygic is not medically reasonable and necessary for the enrollee in this case. Imlygic is not FDA approved for use in combination with Keytruda. Imlygic is not supported for use in this combination in any of the CMS approved compendia. The use listed is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Imlygic. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imlygic havenot been met. Therefore, we decided that the Plan does not have to pre-approve Imlygic for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMs for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 the enrollee has congestive heart failure with preserved ejection fraction requiring hospitalization. In this circumstance, therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. The device is considered experimental/investigational in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMs for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the CMS defining criteria for medically appropriate LTACH admission. You say that the clinical documentation supports the need for LTACH.The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place of an acute care hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a bowel obstruction following removal of a PEG tube. Our physician reviewer found that the enrollee, who has a history of a prior tracheotomy, required repeated intubation/ventilation due to difficulty managing secretions. Our physician reviewer found that the enrollee eventually received a repeat tracheotomy. Our physician reviewer found that the enrollee has since been weaned from the ventilator. Our physician reviewer found that it is unclear if the enrollee is to be decannulated. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required and that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 3, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that you feel that you require continued care in the SNF due to your health. The Plan denied your request. The Plan says you have used up the 120 day SNF benefit for this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The contract with the Plan, however, indicates that it covers up to 120 days per benefit period as an additional benefit. The file shows that you received 120 days of SNF care during the benefit period from July 23, 2019 to January 3, 2020. The Plan has covered 120 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 120 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary, and needs can be met in a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 there is pulmonary debility and exertional dyspnea and no further need for medical or nursing care needs. The enrollee has no endurance to tolerate the intensity of this admission. The enrollee's rehab needs are at a lower intensity level such as 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 IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee