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

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
March 26, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER for chronic pain.
After you were checked in, you had your vital signs taken. You stated that you then waited for three hours and
decided to leave without receiving further care. You stated that you do not believe you should have a bill for
this. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says
that because the allowed amount for the ER visit you had ($67.57) is less than your copayment obligation, you
are responsible for this full allowed 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 the ER visit. This copayment applies regardless of the extent
of services you receive in the ER. 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 emergency room
(ER) visit you had on March 26, 2021
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tandem insulin pump (E0784) Dexcom continuous glucose monitor (CGM) (K0544) supply allowance for therapeutic continuous glucose monitor (K0553).

You asked the Plan to pre-approve the insulin pump, CGM and supplies. You say that you are having a hard time regulating your sugars. You need the device to help regulate your blood sugar. The Plan denied your request. The Plan says no clinical information was received form the provider. The plan had made multiple attempts to obtain the medical records without success.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insulin pump, CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the Tandem insulin pump (E0784) Dexcom continuous glucose monitor (CGM) (K0544) supply allowance for therapeutic continuous glucose monitor (K0553).
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 this is medically necessary for the enrollee. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 3 power wheelchair upgraded electronics or power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300), power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), and power wheelchair electronic connection (E2311). You say that the you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the transfer device is approved with the correct code and although there are three approved power options on the wheelchair there is not a medical need to control the power options through the joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows upper limb strength and function are adequate for you to control the power options using their own switches which are included in the allowance of the power options. A power seat elevation feature is not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature (E2300), power wheelchair expandable controller (E2377), power wheelchair expandable controller harness (E2313), and power wheelchair electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Group 3 power wheelchair upgraded electronics or power seat elevation feature
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 25, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you are unhappy with the quality of care you received. 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on February 25, 2021.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on April 7, 2021 by an
out-of-network (OON) provider.

You asked the Plan to pay for the debridement services. 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 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. The medical record shows the enrollee was seen for an office visit for wound care
assessment and evaluation. 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 debridement services provided on April 7,
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. The Plan denied your request. The Plan says IRF admission 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 pay for 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 that 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 dizziness and a fall and has been discharged home. Medical problems are stable. 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 29, 2020, to August 4, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment 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 $325 copayment per day for days 1-5 for inpatient hospital care.
You have been asked to pay a $325 copayment per day for days 1-5 for the inpatient hospital services. 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 inpatient hospital services you received from July 29, 2020, to August 4, 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 the IRF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services do not meet the requirements for approval.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablets (J8499).

You asked the Plan to pre-approve Otezla. The Plan denied your request. The Plan says Otezla is a self-administered drug and does not fall under Part B coverage.

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 Otezla tablets (J8499).

Benefits for Otezla 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 injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; single level (CPT code(s): 64490 and 64491). You asked the Plan to pre-approve the injections. You say that you are in a lot of pain and need the injection as 
soon as possible. The Plan denied your request. The Plan says there is no clinical information documenting 
medical necessity or that meets Medicare medical necessity criteria. 
 
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 injections. Our physician reviewer 
found the documentation does not indicate that you have received 80% relief from the numbing agent. The 
review has determined that the medical records provided do not meet the requirements listed in the LCD for 
Medicare coverage. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level (CPT 
code(s): 64490 and 64491).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation beyond the Plan's 20-trip 
benefit limit. 
 
You asked the Plan to provide additional routine transportation. You say that you rely on the routine 
transportation to get to appointments. The Plan denied your request. The Plan says your request exceeds the trip 
limit as described in the Plan contract. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year. We looked at your request, the records in the case file, and the rules. The record in the case file shows that the 
request exceeds the Plan's 20-trip limit. Based on this information, we decided that you have exhausted the 
Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to provide additional routine transportation beyond the Plan's 20-trip benefit limit.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirteen (13) additional home health physical therapy visits, for the enrollee.

You asked the Plan to pre-approve the home health services. You say that the services are medically necessary based on cellulitis of right lower limb. The Plan denied your request. The Plan says the request for thirteen (13) home health physical therapy visits has been denied as the criteria in the guidelines have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our physician reviewer found there is no documentation that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Available records do not clarify why the twenty-one (21) total home health physical therapy visits that have been approved by the health plan are inadequate to treat the enrollee's condition.

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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve thirteen (13) additional home health physical therapy visits, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant (CPT code 93580), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee has a history of paradoxical stroke and their condition could be fatal if left untreated. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational in patients over 60 years of age as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file is insufficient to demonstrate that a percutaneous transcatheter closure of a congenital interatrial communication is medically reasonable and necessary for the enrollee in this case. Given the enrollee's age and the lack of a comprehensive evaluation by a stroke neurologist, it is not clear that the procedure is appropriate 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant (CPT code 93580), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (K0011, 
K0108x5, E0973, E0978, E2311). 
 
You asked the Plan to pre-approve the additional accessories. 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 additional accessories. Our reviewer 
says that the requested additional accessories are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested items exceed your medical needs. E0978, K0108 (washer and 
bolts to install seatbelt), and K0108 (hex nuts) are not medically necessary as a seat belt is already included 
with the approved power wheelchair. A K0108 Q Logic exceeds your medical need as a non-expandable 
controller is included in the approved power wheelchair. The E2311 exceeds medical need as there is 
documentation that only actuator was approved. There was no specialty controller approved. You were 
approved for a Group 2 power wheelchair K0835 therefore the code K0011 is not appropriate or medically 
necessary. The E0973 is not medically necessary as you were already approved arm rests in the approved 
wheelchair and power tilt accessories. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional accessories for a power wheelchair (K0011, K0108x5, E0973, 
E0978, E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coronary Computed Tomography (CT) with calcium scoring (75571).
You asked the Plan to pre-approve the CT scan. You say that the services are 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 CT scans are covered only when they are medically 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 the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the record does not indicate the enrollee's cardiac risk factors. The LDL is reported to be 90. The provided records are insufficient to determine whether the requested test would alter the enrollee's management based upon the current guidelines. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Coronary Computed Tomography (CT) with calcium scoring (75571).