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

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not tried Orthovisc.
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 Synvisc. Our reviewer says that the
requirements for coverage of Synvisc have not been met. Our physician reviewer found the Plan requires a trial
of Orthovisc and Monovisc before they will approve the requested drug. While it is documented that the
enrollee received Monovisc injections in 2017, the response to the injections is not documented. The
documentation also does not support that Orthovisc and Monovisc would likely be less effective or have
adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc (J7325).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 21, 2020.

You asked the Plan to pay for the ambulance services. You say that your husband fell and needed this service to assist him getting back up again. 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 October 21, 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 October 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 2, 2021.
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 January 2, 2021. 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 January 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says the member's medical needs can be met with an in-network provider at this time.
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 a portable oxygen concentrator to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on June 18, 2020.
You asked the Plan to pay for the laboratory services. You say that these were medically necessary services and the medical records support the treatment decisions. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 laboratory services provided by an out-of-network provider on June 18, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Pembrolizumab.
You asked the Plan to pre-approve Pembrolizumab. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.
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 Pembrolizumab. Our reviewer says that the documentation does support that the requested drug is medically reasonable and necessary. First-line, single-agent treatment of non-small cell lung cancer (NSCLC) in enrollees with stage III NSCLC (who are not candidates for surgical resection or definitive chemoradiation) or in enrollees with metastatic NSCLC, and with tumors with PD-L1 expression (tumor proportion score [TPS] greater than or equal to 1%), as determined by an approved test, and with no epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations. The enrollee also has 2 sites of disease in the right upper and right lower lobe. Therefore, the enrollee meets criteria for the requested drug. Our physician reviewer found the documentation shows that the enrollee has an FDA approved diagnosis for the use of Pembrolizumab. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan has to pre-approve Pembrolizumab.
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: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 2, 2020 to June 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab testing. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 2, 2020 to June 3, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the $550 cost share charged for emergency room services, advanced imaging and outpatient surgery provided on December 23, 2019.
You asked the Plan to waive or reduce this cost share. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct contract language for each service.
The Plan is correct in this case. 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 cost share for each type of service provided. When you go to the emergency room, only a certain level of service is provided under what is coded as "emergency department" services. The Plan contract clearly states that the $90 copayment for emergency room services is waived if there is a need for advanced imaging such as computed tomography. You required this imaging, and the Plan waived the $90 copayment for emergency room services and charged a $225 copayment for the computed tomography service. The imaging then determined that you required a surgical procedure. A surgical procedure is coded as an outpatient service or an inpatient service, but it is not included under the "emergency room" care services. You were treated under an outpatient hospital level of service for a surgical procedure. The Plan contract is clear that outpatient surgery in a hospital has a copayment of $325.
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 or reduce the $550 cost share ($225 for imaging and $325 for outpatient surgery) charged for emergency room services, advanced imaging and outpatient surgery provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided January 6, 2021.
You asked the Plan to pay for the problem focused dental exam. You say that you don't feel you should have to pay for going to the dentist. The Plan denied your request. The Plan says this service is not covered under your preventative or comprehensive 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 pay for the limited oral evaluation - problem focused (D0140) provided January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 15, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you already paid a $30 for the consultation the day before and received a bill for another consultation. You say that there was no consultation just the ultrasound and injection. The Plan denied your request. The Plan says the copayment 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 $30 copayment for each specialist visit. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show services were provided during the office 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 the office visit provided on December 15, 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 care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The hospital admission was for osteomyelitis, colitis and sacral pressure ulcer. 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. There is no documented need for an intensive rehabilitation program. There a not 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care service provided on March 1, 2020. You asked the Plan to pay for the critical care service. You say that the enrollee was eligible on this day of service so the Plan should pay this claim. The Plan denied your request. The Plan says the hospitalization benefit period started on February 28, 2020 therefore the Plan is not responsible for payment.
The Plan must follow Medicare rules. Medicare rules say that payment for inpatient services until the date of the beneficiary's discharge is made by the previous MA organization or original Medicare, as appropriate. We looked at the file and Medicare rules. The record shows the inpatient period started on February 28, 2020
under a different health plan. Hospital stays and services that began prior to enrollment with this Plan are not covered. Based on this information, we decided that Medicare rules for coverage of the critical care service have not been met. Therefore, we decided that the Plan does not have to pay for the critical care service provided on March 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care provided by an out-of-network provider on December 24, 2020.
You asked the Plan to pay for the initial observation care. You say that the hospital is in-network so no authorization was obtained. You say that the patient did not know which doctors were in-network during their stay and the claim should be reprocessed for payment. 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 initial observation care provided by an out-of-network provider on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 18, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should only be charged one copayment since you had to go to another urgent care provider two days later. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $50 copayment for each in- and out-of-service area Medicare-covered urgent care provider visit. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 urgent care visit provided on January 18, 2021.
Your complaint about the conflict of medication prescribed is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on February 21, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 x-rays provided on February 21, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), the prophylaxis (D1110), and the surgical extraction (D7210) provided on November 2, 2020.
You asked the Plan to pay for the dental services. You say that this was the only provider that could perform these services within 50 miles of you. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a provider who has opted out of Medicare. The Plan says that they confirmed that the provider's office does verbally advise that they do not accept Medicare. The Plan also says there were in network providers available in your area.
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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), the prophylaxis (D1110), and the surgical extraction (D7210) provided on November 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health nursing services provided from April 22, 2016, through April 27, 2016.
You asked the Plan to pay for the nursing services. You say that you are correctly billed for these services on a CMS-1500 claim form. You are not associated with a home health agency so you cannot bill with a UB-04 form. You provided these services and should be reimbursed. The Plan denied your request. The Plan says these services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that direct payment can only be made to providers enrolled in the Medicare program. Licensed practical nurses are not eligible to enroll.
Though these services may have been appropriate, Medicare does not provide direct reimbursement to a licensed practical nurse for them. Therefore, we decided that the Plan does not have to pay for the home health nursing services provided from April 22, 2016, through April 27, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility visit provided by an out-of-network provider on November 19, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the provider is the attending doctor at the facility and the primary care office will not give referrals. You say that this is out of their control and the claim should be processed. The Plan denied your request. The Plan says authorization must be requested and approved prior to rendering the service.
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 nursing facility visit provided by an out-of-network provider on November 19, 2020.