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

We decided that the Plan does not have to reduce the cost for the MRI and the glucagon hydrochloride injection provided on January 9, 2021.
You asked the Plan to reduce the cost for the MRI and the glucagon hydrochloride injection. You say that the procedures should not be charged separately. You say that you were never charged for an injection with an MRI, and you do not agree with the coinsurance charge. The Plan denied your request. The Plan says the cost share applied correctly.
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 $110 copayment for Medicare-covered diagnostic radiology services and 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $150 for the MRI and the glucagon hydrochloride injection.
Service                                                Allowed Amount  Standard Cost  Member Liability  
MRI                                                       $2,625                 $110               $110
Glucagon Hydrochloride Injection             $200                    20%               $40
TOTAL:                                                                                                  $150

The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The glucagon hydrochloride injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based 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 reduce the cost for the MRI and the glucagon hydrochloride injection provided on January 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on January 19, 2021, by a Medicare
opt-out provider.
You asked the Plan to pay for the prophylaxis. You say that you were not advised that the treating provider had
opted out of Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare
effective March 7, 2016, to March 7, 2022. The Plan also says that charges incurred by Medicare opt-out
providers will not be reimbursed.
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 rendered by a Medicare opt out provider. Therefore, we decided that the Plan does not
have to pay for the prophylaxis provided on January 19, 2021, by a Medicare opt-out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of breast implants (19328).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that you had breast implants twenty years ago. You complain of neck and shoulder pain. You would like the breast implants removed because they are old. The physical examination demonstrates grade one ptosis. The breasts are soft without contracture. No other examination abnormalities are noted. No imaging has been performed. The documentation does not indicate that other conservative measures of management have been attempted. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of breast implants (19328).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of daratumumab-hyaluronidase.

You asked the Plan to pre-approve daratumumab-hyaluronidase. You say that this drug is medically necessary for treatment of your condition. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because this would be experimental/investigational and there are other proven treatments that might help you.

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 daratumumab-hyaluronidase. Our reviewer says that you meet the Medicare criteria for the requested use of daratumumab-hyaluronidase. Our physician reviewer found this is a continuation and you cannot stop a drug that is working, so this must be approved as a clinical variance.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of daratumumab-hyaluronidase have been met. Therefore, we decided that the Plan has to pre-approve use of daratumumab-hyaluronidase.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because you are unable to put weight on your foot and surgery is necessary. The Plan denied your request. The Plan says your needs may be safely met in a lower 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require the services on an inpatient basis, only in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3000) provided December 10, 2020.
You asked the Plan to pay for foot orthotics. You say that the orthotics were medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000) provided December 10, 2020.
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 is stable and ready for transfer. The Plan denied your request. The Plan says the guidelines for LTACH care have not been met.

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 was admitted following acute on chronic respiratory failure. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 10, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on September 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the visual field examination (92083) and scanning computerized ophthalmic diagnostic imaging of optic nerve (92133) provided March 2, 2021.
You asked the Plan to waive the deductible for the visual field exam and computerized ophthalmic diagnostic imaging. You say that you thought these services were part of your preventative glaucoma screening and not subject to the deductible. The Plan denied your request. The Plan says that these services are not considered preventative and the deductible was applied correctly.
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 there is a $125 deductible for outpatient diagnostic tests and therapeutic services and supplies. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $125 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the visual field exam and computerized ophthalmic diagnostic imaging was received on March 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the visual field examination (92083) and scanning computerized ophthalmic diagnostic imaging of optic nerve (92133) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0800).
You asked the Plan to pre-approve Group 1 power wheelchair. You say that this requested wheelchair is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 Group 1 power wheelchair. Our reviewer says that the requested power wheelchair is not medically reasonable and necessary. Our physician reviewer found in this case, the documentation demonstrates that the patient has a mobility limitation that impairs her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. In addition, the documentation also reveals that the patient's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately cane, manual wheelchair, walker due to fatigue, shortness of breath, falls. However, the documentation does not reveal that the patient's home provides adequate access for the requested wheelchair and that the use of the wheelchair will significantly improve the patient's mobility-related activities of daily living. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 1 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0800).
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 you want to be admitted to the LTACH
in order to get stronger. The Plan denied your request. The Plan says you are receiving appropriate inpatient
acute care in your current setting and you do not require transfer to a LTACH.
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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided November 23, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT codes billed are not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes S1015, & S8301 are not supported in the medical record. Specifically, per the National Physician Fee Schedule, the CPT codes billed have a status of "I" and are not eligible for Medicare payment.. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (S1015, S8301) provided November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary The Plan denied your request. The Plan says you do not meet the required criteria to be admitted to the IRF.

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 that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of cervical fractures after a fall. Medical conditions are stable. You require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for high intensity focused ultrasound (HIFU) imaging for the enrollee.
You asked the Plan to provide coverage for this imaging which you say 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 stating Maximus did not apply the correct LCD criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only covers this imaging for recurrent prostate cancer. The medical records clearly state this is first line treatment and the enrollee has not had radiation. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to provide coverage for high intensity focused ultrasound (HIFU) imaging for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for levonorgestrel intrauterine device (IUD) provided September 22, 2020.

You asked the Plan to pay for levonorgestrel IUD. You say that the requested item was medically necessary.
The Plan denied your request. The Plan says that the coverage criteria have not been met in this case.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 pay for levonorgestrel IUD. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the IUD is not being used for contraception. The levonorgestrel IUD is FDA-approved for the
treatment of heavy menstrual bleeding and is used widely in the field of gynecology for this purpose. It is safe
and effective. It is medically reasonable and necessary for the member to have her LNG-IUD replaced for the
continued treatment of heavy menstrual bleeding.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of levonorgestrel IUD have been met. Therefore, we decided that the Plan has to
pay for levonorgestrel intrauterine device (IUD) provided September 22, 2020.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on December 30, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on December 30, 2020.

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.