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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425,
A0427) received January 21, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford
the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $240
copayment for Ambulance Services.

You have been asked to pay a $240 copayment for the ambulance transportation. The ambulance transportation
falls within the Ambulance Services 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
the ambulance transportation (A0425, A0427) received January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary.The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that based upon the records provided,you do require daily skilled therapy services. However, you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued services in the acute inpatient rehabilitation facility appear appropriate in this case and the health plan has indicated that it will continue to cover this level of care until you are stable to transfer to 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care provided from December 5, 2020, through December 23, 2020.You asked the Plan to pay for the home health care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 1, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay for home health care provided from December 5, 2020, through December 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is still a necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that, based on the documentation provided, you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on January 25, 2021.

You asked the Plan to pay for the nursing facility visit. You say that the treatment received was medically necessary and the physician provided a statement of medical necessity. The Plan denied your request. The Plan says the service was provided by an out-of-network provider without authorization.

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 nursing facility visit provided by an out-of-network provider on January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received January 12, 2021.You asked the Plan to waive the copayment for the ambulance transportation. You say that you have never had to pay for ambulance services before.The Plan denied your request. The Plan says the correct cost share applied to the claim.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 $240 copayment for Ambulance Services. You have been asked to pay a $240 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 the ambulance transportation (A0429, A0425) received January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant, lower left quadrant and lower right quadrant (D4921) and add metal structure to acrylic full denture (per arch) (D5876).

You asked the Plan to pre-approve gingival irrigation and metal substructure for dentures. You say that you would like the services reconsidered. The Plan denied your request. The Plan says these services are not covered under the enrollee's dental benefits.

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 gingival irrigation - per quadrant, lower left quadrant and lower right quadrant (D4921) and add metal structure to acrylic full denture (per arch) (D5876).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on October 16,
2020.

You asked the Plan to waive the copayment for emergency care. You say that your only option was to receive
medical care from a local health care facility. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received the emergency care on October 16, 2020. You were asked to pay a
$90 copayment for the emergency care. Your 2020 EOC states that enrollees must pay a $50 copayment for
each Medicare-covered emergency room visit. 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 October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received February 9, 2021.

You asked the Plan to pay for the limited oral evaluation - problem focused (D0140). You say that the requested service was necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair seat elevation feature.You asked the Plan to pre-approve a power wheelchair seat elevation feature (E2300). You say that you have problems standing without support.The Plan denied your request. The Plan says the seat lift does not serve a medical purpose and cannot be covered.
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 and is statutorily excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair seat elevation feature.
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 it is felt that IRF care is needed.The Plan denied your request. The Plan says the enrollee's medical conditions are stable, and a hospital level of care is not required.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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure and right thigh cellulitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.You asked the Plan to pre-approve spinal surgery. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of postoperative instability or fracture. There is no documentation of recent physical therapy for back pain. Additional spinal fusion surgery is not medically needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trilogy home ventilator.
You asked the Plan to pre-approve the Trilogy home ventilator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the home ventilator is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 Trilogy home ventilator. Our reviewer says that CO2 retention has not been demonstrated and BiPAP has not been tried. Our physician reviewer found Medicare does not cover a home ventilator when used as BiPAP, and certain BiPAP devices can provide the average volume-assured pressure support mode that has been ordered. 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 Trilogy home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Trilogy home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a urinary tract infection and cellulitis of a toe. Medical conditions 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. You do 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion.

You asked the Plan to pre-approve spinal fusion. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 spinal fusion. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the interspinous device remains experimental. More research is needed to show safety and
efficacy. Also, there is no recent trial and failure of physical therapy for back pain and/or spinal instability at
any level documented. Spinal fusion is not medically needed at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal fusion have not been met. Therefore, we decided that the Plan does not
have to pre-approve spinal fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have pain and discomfort walking. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee.

You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary. The Plan denied your request.

The Plan says the required step therapy criteria are not met. Maximus overturned the Plans denial because the case file did not contain complete contract information. The Plan requested a reopen and provided the contract information required for review.

Our Medical Director looked at the case file. At issue is whether Evenity is a covered service for the enrollee under Medicare rules. Medicare rules also allow the plan to use step therapy. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. The Plan requires enrollees to try and fail either Prolia or Relcast prior to receiving coverage for Evenity. In this case, the medical record only contains a conclusory statement that does not provide sufficient medical rationale as to why Evenity was requested for the enrollee. There are no medical records submitted that support the medical necessity of the requested drug in this clinical scenario. 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor (K0553, K0554).