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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical/thoracic interlaminar epidural injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the notes do not clearly document the degree and duration of pain relief from the prior injections. There has also not been a surgical consultation regarding the extruded disc which is effacing the cord. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical/thoracic interlaminar epidural injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on December 10, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare
denies coverage of all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that service, the information submitted by the
supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and Medicare rules. In this case, the medical records provided do not show that the results
of the molecular pathology testing would be used in the management of the enrollee's specific medical
problem. Based on this information, we decided that Medicare rules for coverage of the services provided have
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on
December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 x2) for the enrollee.
You asked the Plan to pre-approve this device. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 x2). The Maximus Physician Reviewer determined that the enrollee had a history of chronic low back pain. The pain can is attributed to the lumbar spine and is the result of a nerve root injury (compression). The enrollee was evaluated by a neurosurgeon who believes the enrollee met the criteria required. The Plan requested a reopen and stated that the diagnosis rendered by the treating physician was lumbar disc herniation with radiculopathy which is not a covered diagnosis under Medicare guidelines.
Our Medical Director has concluded that the Plan is correct in this case. The medical records show the enrollee is a 70-year-old man with a diagnosis of lumbar disc herniation with radiculopathy and chronic pain syndrome. The documentation in the case file does not support that the coverage criteria as established by NCD 160.7 and LCD L35450 were met in this case as the enrollee does not have a diagnosis which qualifies as a covered indication. Medicare coverage criteria are not met. 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 device have not been met. Therefore, we decided that the Plan does not have to provide coverage for percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 x2) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 an additional ten (10) PT 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 that based on the available records the enrollee appears to have improved with therapy to the point of being able to manage gym exercises. Further treatment at this point does not appear to require the skills of a professional therapist. Further utilization of the home/gym exercise program appears appropriate at this point. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.
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 additional ten (10) PT visits. have not been met. Therefore, we decided that the Plan does not have pre-approve an additional ten (10) PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on November 13, 2020, and November 27, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with charges and feel that you should have been given more treatment options. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. The enrollee received a Medicare Part B drug on November 13, 2020. The allowed amount is $2,089.80 and 20% of that is $417.96. The enrollee received a Medicare Part B drug on November 27, 2020. The allowed amount is $2,089.80 and 20% of that is $417.96. The total amount you owe is: $835.92. The enrollee has been asked to pay the total coinsurance amount of $835.92 for Medicare Part B drugs.
Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on November 13, 2020, and November 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana for the enrollee.
You asked the Plan to pre-approve Brovana. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication Perforomist would likely be less effective, and/or cause adverse effects for the member.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Brovana. Our reviewer says that Brovana is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Perforomist. There is no indication that Perforomist would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Brovana. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 17, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you are unhappy with the care you received and feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on December 17, 2020.
Your quality of care concerns will be forwarded to the appropriate Quality Improvement Organization for review. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre sensor for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says doses are not adjusted based on blood sugar levels.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee injects insulin twice a day and does not adjust the dose frequently. The enrollee checks her sugar twice daily. The elements of the coverage rule 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoCycle Home therapy system.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.

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 system. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has multiple sclerosis. he requested device has not been demonstrated to be of benefit to
treat the enrollee's condition. The medical record indicates that the requested service is part of a trial at the
requesting institution.

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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve the MyoCycle Home therapy system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided by an out-of-network provider from January 8, 2021, through February 5, 2021.
You asked the Plan to pay for the psychotherapy. You say that the enrollee expressed an unwillingness to work with another provider and you were able to treat her at an outpatient level of care. You say that the claims should be approved to continue the interventions she needs. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 psychotherapy provided by an out-of-network provider from January 8, 2021, through February 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 1, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says you are not an eligible Medicare provider. Maximus overturned the Plans denial administratively as the Plan had not provided documentation to substantiate their denial. The Plan requested a reopen and provided additional documentation to show that you are not an eligible Medicare provider and that you were not eligible to bill Medicare at the time of service.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not eligible to bill Medicare. These services were provided in a non-urgent, non-emergent situation by the provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that this provider is closer and would like to go there. 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 specialist 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 an ultralightweight wheelchair and accessories.
You asked the Plan to pre-approve an ultralightweight wheelchair (K0005) and accessories. You say that the enrollee needs an ultralightweight wheelchair and accessories. The Plan denied your request. The Plan says Medicare excludes separate coverage of durable medical equipment for enrollees who reside in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that an ultralightweight wheelchair (K0005) and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair and accessories.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from December 9, 2020, through January 16, 2021 billed with code 2BFKT.
You asked the Plan to pay for the home health services as billed. You say that this claim should be paid as billed. The Plan denied your request. The Plan says this claim was billed with a HIPPS code indicating that NRS were provided; however, there is no line item for NRS items.
The Plan must follow Medicare rules. Medicare rules say that for home health claims in which no NRS are provided, the final HIPPS code reported should have a number 1-6 reported as the fifth digit. In order to report a HIPPS code with a letter S-X, there must be a line item in which the provision of NRS is reported. In this case, the fifth digit of the reported HIPPS code is "T". This would indicate that NRS were provided during the episode of care. However, there are no line items reporting a revenue code in the 027X range, excluding 274, or revenue code 623. Since no NRS items were billed on the claim, the use of a letter as the fifth digit of the HIPPS code is not supported. Therefore, we decided that the Plan does not have to pay for the home health services provided from December 9, 2020, through January 16, 2021 billed with code 2BFKT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 28, 2020.

You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says this visit exceeds the benefit limit.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the wig (A9282) provided on March 3, 2020.

You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to issue reimbursement for the wig (A9282) provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says you have a stable gait and are neurologically intact.

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 scooter. Our reviewer says that the
requested scooter is not medically reasonable or necessary. Our physician reviewer found the physician
medical progress report does not support that you have a personal mobility deficit that impairs participation in
MRADLs. There is no indication of why you would be unable to use a walker, cane, or wheelchair. There is no
documentation on whether you can safely operate the scooter. Progress report notes stable gait, no
motor or sensory deficits, and normal reflexes.

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 scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electric scooter.