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

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve outpatient mental health services. You say that this was the only provider you found who was accepting new patients. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 outpatient mental health 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 Nivolumab and Ipilimumab.
You asked the Plan to pre-approve Nivolumab and Ipilimumab. You say that these drugs are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says these drugs are not FDA approved or compendia recommended for the enrollee's condition.
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 Nivolumab and Ipilimumab. Our reviewer says that the requested drugs are not medically necessary and reasonable. Our physician reviewer found the enrollee is a 75-year-old with non-small-cell lung carcinoma. The requested drugs are not FDA-approved for the enrollee's condition. In addition, their use for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab and Ipilimumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab and Ipilimumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete mandibular denture.
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like the dentures to be approved for coverage. The Plan denied your request. The Plan says dentures are specifically excluded from coverage, and are not covered for any reason.
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 a complete maxillary denture and a complete mandibular denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on January 19, 2021, billed with code 99309 on the same date as code 11043.
You asked the Plan to pay for the EM services as billed. You say that this is billed correctly since more than one wound was treated on the date of service. The Plan denied your request. The Plan says the EM visit was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that EM services provided on the same date as a minor procedure as generally not separately payable. If the service is a significant, separately identifiable service, not related to the surgical procedure, modifier -25 is required to allow for payment. In this case, code 99309 was billed on the same date of service as 11043 (a minor surgical procedure) and 11046. Without reporting modifier -25, separate payment cannot be made for the EM service. Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services provided on January 19, 2021, billed with code 99309 on the same date as code 11043.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the right knee (64624).
You asked the Plan to pre-approve a radiofrequency ablation of the knee. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a radiofrequency ablation have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a radiofrequency ablation of the knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has right knee osteoarthritis. The enrollee takes non-steroidal anti-inflammatory drugs (NSAIDs) and has had an intra-articular corticosteroid injection of the right knee. The enrollee underwent diagnostic right genicular nerve blocks and had significant pain relief. The requested procedure is an experimental/investigational procedure that is the subject of on-going clinical trials. 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 radiofrequency ablation of the knee have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the right knee (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective outer surface covering.

You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the artificial leg will not be used in very harsh conditions.

The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not show that the prosthesis needs protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a protective outer surface covering.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone 10mg/Act gel.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Testosterone 10mg/Act gel.
Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip, lab work, physical therapy, and a specialist office visit provided by participating providers on November 27, 2020, to January 21, 2021.
You asked the Plan to waive the copayment for an ambulance trip, lab work, physical therapy, and a specialist office visit. You say that you should not have to pay for this because it was all directly related to your Covid-19 hospital stay. The Plan denied your request. The Plan says the correct copayments have been applied to the services that were provided.
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 $300 copayment for ambulance services/in-network, a $20 copayment for outpatient diagnostic tests/in-network/lab tests, a $35 copayment for physician/practitioner services/in-network/specialist, a $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $300 copayment for an ambulance trip, a $20 copayment for lab work, a $35 copayment for a specialist office visit and, a $40 copayment for physical therapy.
Total Amount Being Asked to Pay: $590 ($300 + $35 + 20 + $40 + $40 + $40 + $40 + $35 + $40 = $590)
An ambulance trip falls within the ambulance services/in-network benefit category, lab work falls within the outpatient diagnostic tests/in-network/lab tests benefit category, physical therapy falls within the outpatient rehabilitation services/in-network benefit category, and a specialist office visit falls within the physician/practitioner services/in-network/specialist 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 waive the copayment for an ambulance trip, lab work, physical therapy, and a specialist office visit provided by participating providers on November 27, 2020, to January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 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 device for the enrollee.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for shipping charges applied for durable medical equipment purchased from on online vendor.
You asked the Plan to reimburse you for shipping charges. You say that the Plan should cover the shipping. The Plan denied your request. The Plan says Medicare and the Plan do not cover shipping from online sites. Maximus overturned the Plans denial. The Plan stated that Maximus did not apply the correct contract criteria.
The Plan is correct in this case. When enrollees choose to have equipment shipped directly to their home as opposed to picking the equipment up directly from a vendor stocked location, those shipping charges are not covered by Medicare or the Plan as this was done for convenience. Most providers absorb that cost for the enrollee or include the cost in the cost share or coinsurance. The Plan is not required to hold you harmless or reimburse you for shipping costs incurred due to your choice to have the equipment shipped. If the Plan has reimbursed you based on the prior decision, please understand they are not required to do so in the future. Therefore, we decided that the Plan does not have to reimburse you for shipping charges applied for durable medical equipment purchased from CPAP.com
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a 64-year-old female who was admitted to an acute care hospital on May 7, 2021. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at 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 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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the EMTALA charges, 28 hours observation and ancillary charges including the fees for diagnostic testing and medication provided from November 19, 2020, through November 24, 2020.
You asked the Plan to pay for the EMTALA charges, 28 hours observation and ancillary charges including the fees for diagnostic testing and medication. You say that you are not seeking payment for the inpatient portion of the claim. You say that state law prohibits you from changing the level of care status. The Plan denied your request. The Plan says the charges should be carved out and billed separately from the inpatient charges.
The Plan must follow Medicare rules. Medicare rules say that when an inpatient admission is found to be not reasonable and necessary, the Centers for Medicare & Medicaid Services (CMS) will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, except for those services that specifically require an outpatient status such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatients and not inpatients. We looked at the file and Medicare rules. The rules say if an enrollee was admitted as an inpatient and payment cannot be made for inpatient care leading to claim denial, the provider can be paid for the emergency room services and observation services provided prior to formal admission, if they submit a standard Part B outpatient hospital claim, which are TOB 131, as well as certain services that were provided after the point of admission, if they would be covered if rendered to an outpatient, on a second Inpatient Part B claim with the TOB 121. Therefore, we decided that the Plan does not have to pay for the EMTALA charges, 28 hours observation and ancillary charges including the fees for diagnostic testing and medication provided from November 19, 2020, through November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a lymphedema sleeve. You say that you would like approval for this equipment to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers 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 durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for a Hernia repair.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is
medically necessary. The Plan denied your request. The Plan says the enrollee is stable for the procedure to be
performed in the outpatient setting.
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 pre-approve 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 the documentation does not indicate that the enrollee is not medically
stable or requires any inpatient level of care services for the procedure.
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 pre-approve an inpatient hospital admission for a Hernia repair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5100) and a hearing assessment (V5010) from an out-of-network provider.
You asked the Plan to pre-approve the out-of-network hearing services.. You say that you currently use a provider in a different network and feel it is more convenient to use this provider than see a new one. The Plan denied your request. The Plan says routine hearing services must be provided through the specified hearing network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and routine services only when they are provided by a provider in the Plan's specified network. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the out-of-network hearing services. have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5100) and a hearing assessment (V5010) from an out-of-network provider.