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

We decided that the Plan does not have to pay for the preparation and provision of single-dose vials of allergen antigens for allergy immunotherapy, for sublingual administration, provided from May 7, 2020, to September 15, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 pay for the preparation and provision of single-dose vials of allergen antigens for allergy immunotherapy, for sublingual administration, provided from May 7, 2020, to September 15, 2020.
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker.
You asked the Plan to pre-approve a heavy duty walker. You say that you would like reconsideration because you recently fell and spent time in the hospital. The Plan denied your request. The Plan says Medicare provides heavy-duty walkers for members that weigh over 300 pounds.
The Plan must follow Medicare rules. Medicare rules say that If a heavy duty walker is provided and if the beneficiary weighs 300 pounds or less, it 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 a heavy duty walker have not been met. Specifically, the record indicates that you are not over 300 pounds. Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided January 8, 2021.
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan denied your request. The Plan says an appropriate diagnosis code was not billed.
The Plan must follow Medicare rules. Medicare rules say that PET scan services must be billed with an appropriate oncologic diagnosis. We looked at the file and Medicare rules. The diagnosis code billed (R59.0) is not listed an appropriate diagnosis code for the PET scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have vertigo and are at risk of falling in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with intraventricular hemorrhage after a mechanical fall. He currently needs contact guard assist with transfers, toilet hygiene, and ambulation. Multiple therapy notes state he declined therapy. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the zippered pocket and seat pouch

You asked the Plan to pre-approve the zippered pocket and seat pouch. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested items do not meet the definition of durable medical equipment.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the zippered pocket and seat pouch
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to remove the charges for radiation therapy treatment planning provided on November 5, 2020, and November 9, 2020.
You asked the Plan to remove the charges for the radiation treatment planning. You say that you feel this should not have been paid because you received this treatment from another facility. The Plan denied your request. The Plan says it is noted that you were planning to undergo treatment with this provider, and treatment planning was performed prior to you receiving treatment elsewhere.
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 20% coinsurance for radiation therapy. You have been asked to pay 20% coinsurance for the radiation treatment planning. The radiation treatment planning falls within the radiation therapy benefit category. Although you did not ultimately receive the radiation treatment from this provider, the planning services are a separately payable service. 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 remove the charges for radiation therapy treatment planning provided on November 5, 2020, and November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says despite multiple attempts, records were not received.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Despite multiple attempts by the plan, records to prove the medical necessity of this monitor were not received. It cannot be determined that you meet the criteria. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from May 15, 2021, forward.
You asked the Plan to pre-approve SNF 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 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 there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary treatment. You do not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are not required to safely and effectively provide medically necessary treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from May 15, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence of insulin use. 

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that the enrollee is not maintained on insulin therapy. The enrollee has not been using insulin multiple times (3 or more) a day. His treatment does not require frequent adjustment on the basis of testing results. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239) and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).
You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia. The Plan denied your request. The Plan says these services are not covered.
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 the first 15 minutes of intravenous moderate (conscious) sedation/analgesia (D9239) and three subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia (D9243 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor and appliance to be provided by an out-of-network provider.
You asked the Plan to pre-approve the pneumatic compressor and appliance. You say that you are the doctor's preferred provider for distributing specialized medical equipment. You say that the member has failed several conservative treatments and the appeal should be overturned so the patient can begin her therapy in home. The Plan denied your request. The Plan says in-network providers are available.
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 the pneumatic compressor and appliance to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve the abutment supported crown. The Plan denied your request. The Plan says this service is not covered.
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 an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management specialist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 referral to an out-of-network pain management specialist.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional skilled therapy visits (G0151).
You asked the Plan to pre-approve the additional skilled therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria for continued skilled therapy is not 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 additional skilled therapy visits. Our reviewer says that the additional skilled therapy visits are not medically necessary. Our physician reviewer found the enrollee has had prior therapy and the records do not demonstrate that the enrollee's functional level needs the unique skills of a professional therapist. The enrollee is compliant with a home exercise program. 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 skilled therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional skilled therapy visits (G0151).
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 the 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 pre-approve the 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 knee replacement surgery. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 the 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 inpatient services provided to the enrollee on September 18, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. After additional information was discovered about the enrollee's hospice election, Maximus reopened the appeal.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The enrollee ended Medicare Hospice benefits on September 14, 2020. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient services provided to the enrollee on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the $563.39 coinsurance charged for outpatient hospital services provided from August 3, 2020, and August 7, 2020.

You asked the Plan to reduce this coinsurance. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the claim submitted by the provider and the Plan contract agreement. Maximus overturned the Plans denial and instructed a reduction to $250 for outpatient surgery. The Plan requested a reopen and stated that Maximus did not apply the correct contract benefit. The Plan stated that you are appealing two different dates of service. The Plan states the providers claim has processed correctly with a 20% coinsurance as the provider billed this service with Bill Type of 137, which is outpatient hospital and not outpatient surgery.

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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient hospital services. The claim was billed by your physician and the provider as outpatient hospital services. 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 reduce the $563.39 coinsurance charged for outpatient hospital services provided from August 3, 2020, and August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation.

You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit under your plan.

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 a cone beam CT capture and interpretation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 3, 2020.

You asked the Plan to pay for the office visit. You say that you were unable to get authorization before the service was done due to the short time period. You say that the records show the necessity of the service and the claim should be considered 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 the office visit provided by an out-of-network provider on December 3, 2020.