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

We decided that the Plan does not have to pre-approvea facet injection (64490).You asked the Plan to pre-approvea facet injection. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that facet joint interventions may be used in pain management for chronic neck and back pain arising from the paravertebral facet joints.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 facet injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has radicular symptoms, documented degenerative disc disease and spinal stenosis and had a prior cervical epidural steroid injection which helped. However, the request is for cervical facet injection. The request is not medically reasonable and isnot necessary.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 facet injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea facet injection (64490).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression profiling services coded 0012M provided on August 6, 2020. You asked the Plan to pay for the oncology gene expression profiling services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The oncology gene expression profiling services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the oncology gene expression profiling services coded 0012M provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene analysis services provided on September 18, 2019.

You asked the Plan to pay for the gene analysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The gene analysis services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the gene analysis services provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that you were unaware that authorization was needed or you were out-of-network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 7, 2020 by an out of network (OON) provider.
Sincerely,
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bone Marrow Aspiration for the enrollee.

You asked the Plan to pre-approve this treatment. You say that this treatment is medically necessary. The Plan denied your request. The Plan says this treatment is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this treatment is an emerging technique, but it is not the standard of care at this point. Medicare continues to find this treatment experimental. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Bone Marrow Aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment foran office visit provided on September 8, 2020.You asked the Plan to waive the copayment foran office visit. You say that you disagree with the charges because this was your annual wellness visit.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records. Without medical records we cannot determine whether or not the office visit was an annual wellness visit or not.Therefore, we decided thatthe Plan has to waive the copayment foran office visit provided on September 8, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF)services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that SNF admission 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 Medicare pays for care in a SNF when the four factors listed above 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 the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other ongoing SNF level skilled nursing need. The documentation does not reveal significant pulmonary symptoms, need for additional nursing assist nebulizer treatments, imaging studies. The enrollee appears to be medically stable. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 pay for the medical services provided on September 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 15, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.

You asked the Plan to pre-approve Botox. You say that this drug 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the review indicates that the enrollee is a 62-year-old female who has a large, incarcerated ventral hernia without obstruction. The request for Botox injection is to reduce hernia size prior to surgical repair. The documentation indicates that the enrollee has an abdominal wall hernia containing the small bowel, colon and portion of the anterior gastric body. No bowel obstruction. An Abdominal binder does not fully resolve the issue of massive hernia .Pharmacological paralysis of the lateral abdominal muscles appears promising as a supplementary preoperative method to achieve primary fascial closure in repair of large ventral hernias. At present, safety, efficacy, and feasibility of Botox cannot be fully evaluated due to lack of controlled data and limited details regarding indications and contraindications. Before Botox therapy becomes more widespread as a preoperative therapy, comparative cohort data on indication, application techniques, dosing, efficacy, safety, and costs are required. There was no support found in compendia (Drudge, Clinical Pharmacology, Lexi-Drugs, AHFS-DI, NCCN, Medicare-approved Journals) for the use of Botox as chemo-denervation preoperatively for reconstruction after hernia repair. The review has determined that the documentation does not support that the Botox is medically reasonable or necessary for the enrollee. The documentation does not support that the Botox is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the Original Medicare cost share applied to outpatient mental health care provided from June 17, 2020, to August 12, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says your dual special needs contract applies your Medicare benefits to the services you receive, this includes the Medicare deductible, coinsurances, and copayments. At the time these claims processed, you had already met your Medicare deductible. The claims applied the Original Medicare Cost share in accordance with the Medicare and You 2020 Handbook which indicates a 20% coinsurance applies to services after the Part B deductible is met. Medicaid should have picked up the cost share, but based on your statements, they did not due to the provider being out-of-network with Medicaid. Your Medicaid benefit should be through the State of Michigan or another insurance carrier. The Plan says that if Medicaid has denied these services, you will need to pursue appeals with the appropriate carrier of your Medicaid benefits. However, the claims processed by the Plan were processed correctly in accordance with your contract and your Medicare 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). The cost share for this benefit was applied to Original Medicare due to your dual contract status. Any further cost share that was not picked up by your Medicaid benefit must be appealed to that carrier. Neither the Plan nor Maximus has jurisdiction over your Medicaid benefits. Therefore, we decided that the Plan does not have to waive the Original Medicare cost share applied to outpatient mental health care provided from June 17, 2020, to August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that for chiropractic care, the Plan covers manual manipulation of the spine to correct subluxation. Services are covered when provided by a Plan Provider or a chiropractor when referred by a Plan provider. You can see this on page 29 of the 2020 Evidence of Coverage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and remote joystick.
You asked the Plan to pre-approve a power seat elevation system and remote joystick. We note the Plan approved the requested power wheelchair and Medicare allowed accessories. You say that the requested items are medically necessary. The Plan denied your request. The Plan says the power seat elevation system and remote joystick are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare does not cover a power seat elevation system or remote joystick. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and remote joystick.
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 IRF admission 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 above. 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for dysphagia after a recent stroke. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The records do not  document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee  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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darifenacin 15 mg tablet.

You asked the Plan to pre-approve Darifenacin. You say that the services requested are medically necessary. The Plan denied your request. The Plan says the enrollee's drug coverage is limited to those drugs covered under the medical benefit only.

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 Darifenacin 15 mg tablet. 

Benefits for Darifenacin 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve below the knee flexible protective outer surface covering system (L5962).

You asked the Plan to pre-approve below the knee flexible protective outer surface covering system. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or a preparatory 
below knee prosthesis (L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of below the knee flexible protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve below the knee flexible protective outer surface covering system (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a life alert system.

You asked the Plan to pre-approve a life alert system. You say that a life alert system is medically necessary. The Plan denied your request. The Plan says a life alert system is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Life alert systems and devices are precautionary in nature and are not covered. While this item may be beneficial to you, it is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a life alert system.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an Epidural Steroid Injection.

You asked the Plan to pre-approve Epidural Steroid Injection. You say that this treatment is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this injection. 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 Epidural Steroid Injection. Our reviewer says that the requested injection is medically reasonable and necessary in this case. Our physician reviewer found the records show you had good results from prior injections. Medicare coverage criteria are 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 Epidural Steroid Injection have been met. Therefore, we decided that the Plan has to pre-approve an Epidural Steroid Injection.

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.