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

We decided that the Plan does not have to pay for the cardiovascular (CV) risk assessment testing (CPT code
81404) provided to the enrollee on January 26, 2021, by Hematopathology Associated LLC.
You asked the Plan to pay for the testing. You say that the treatment sought is medically necessary to treat the
enrollee based on the enrollee's medical condition. The Plan denied your request. The Plan says the diagnosis
does not substantiate service. The Plan must follow Medicare rules. We looked at the file and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of the testing have not been met.
Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel,
for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the
Plan does not have to pay for the cardiovascular (CV) risk assessment testing (CPT code 81404) provided to
the enrollee on January 26, 2021, by Hematopathology Associated LLC.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for retina surgery provided on February 25, 2021.

You asked the Plan to waive the copayment for outpatient surgery. You say that you were never made aware of any copayment and it was confirmed by a Plan representative that there was no surgery copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $125 copayment for outpatient surgery at an ambulatory surgical center. You have been asked to pay $125 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Outpatient Hospital Facilities and Ambulatory Surgical Centers 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 retina surgery provided on February 25, 2021.

Your complaint regarding not being told about the cost-sharing for this service is considered to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please contact the Plan for more information about your grievance.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the home infusion therapy provided from January 7, 2021, through January 14, 2021.

You asked the Plan to waive the deductible for the home infusion therapy. You say that there would not have been a copayment if the medication was in pill form. You say that this was not medical equipment and should be billed under the drug plan. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined in-network and out-of-network deductible is $198. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Home infusion therapy" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $198 deductible applies to home infusions. This cost sharing is a contractual obligation that had not been met at the time the home infusions was received from January 7, 2021 to January 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the home infusion therapy provided from January 7, 2021, through January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vertiflex deveice (22869, 22870).
You asked the Plan to pre-approve the vertiflex device. You say that the services are medically necessary. The
Plan denied your request. The Plan says the services are 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 vertiflex device. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the vertiflex device is experimental and more research is needed to show its safety and efficacy.
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 vertiflex device have not been met. Specifically, there is not enough
research showing the safety and efficacy of this service. This means the service is not medically necessary or
reasonable. Therefore, we decided that the Plan does not have to pre-approve the vertiflex deveice (22869,
22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

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 are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on January 12, 2021.
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on January 12, 2021.
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 services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you do not have any complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intense rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the beneficiary does not require skilled nursing or therapy services on a daily basis or at an inpatient level. 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. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management provided on January 10, 2019 by an OON provider.
You asked the Plan to pay for the nursing facility discharge day management. You say that this claim was initially filed to another insurance as a facility claim. The Plan denied your request. The Plan says this claim was received on December 1, 2020, which is outside of the 12-month filing period.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the nursing facility discharge day management was not filed until December 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the nursing facility discharge day management provided on January 10, 2019 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that you need the injections because you are in pain. The Plan denied your request. The Plan says the records do not show that you have failed physical therapy or medications for at least 3 months, and it did not help with your pain. The Plan also says that you have not tried steroid injection into your knee, and you have not tried the preferred medications.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for you. Our physician reviewer found the Plan requires a trial of drugs Gel-One, Orthovisc, Synvisc, Synvisc-One, or Visco-3 before they will approve the requested drug. Our reviewer found that in this case, you have not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your medical conditions are stable and you do not have complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 27, 2021.

You asked the Plan to pay for an eye refraction. You say that the service at issue was done as part of a routine exam. The Plan denied your request. The Plan says the service at issue is not a covered benefit. Eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. The record shows this service was performed for medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on January 27, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires inpatient rehabilitation to fully recover. The Plan denied your request. The Plan says the enrollee's care can be provided safely at a less intensive setting of care.
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 there are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided February 18, 2021, to February 26, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you believed you were eligible for payment for the services rendered. The Plan denied your request. The Plan says this provider is not eligible for payment by Medicare.
The Plan must follow Medicare rules. Medicare rules say that there are certain provider types that are ineligible for payment by Medicare. We looked at the file and Medicare rules. In this case, the provider is a licensed mental health counselor and not eligible to be certified with Medicare. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided February 18, 2021, to February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospital (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 

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. Specifically, medically necessary services are being obtained at the enrollee's current level of care.

This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.