Persius/hicric huggingface dataset:
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 LTACH care is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded drug services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay for the compounded drug services.

Benefits for these services 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient behavioral health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that other facilities are depressing. The Plan denied your request. The Plan says the facility is out of network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient behavioral health services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frame with trifocal lens and anti-reflective lens coating.

You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

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. Review of the file show that you purchased an eyeglass frame with trifocal lens and anti-reflective lens coating. The total cost of the eyeglass was $529. The benefit of $150 allowance was applied to the purchase, leaving a member's responsibility of $379. The health plan contract states, "We provide a $150 allowance once every 24 months for you to use toward the purchase price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact lens for vision correction. If the eyewear you purchase costs more than $150, you pay the difference." Therefore, we decided that the Plan does not have to pay for the eyeglass frame with trifocal lens and anti-reflective lens coating.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. Our Medical Director says that at issue is coverage for Keytruda (Pembrolizumab) and Zoledronic acid. The Maximus Physician Reviewer determined that Keytruda with zoledronic acid was medically reasonable and necessary. The Plan argues that there is no established evidence to support the use of Pembrolizumab for metastatic tumor mutational burden (TMB) unknown metastatic thyroid cancer. The medical records show the enrollee is a 70-year-old woman with a diagnosis of metastatic poorly differentiated insular-type thyroid carcinoma and infiltrative papillary carcinoma. Metastatic disease is present in the right lung, right hilum, and bone.

Our Medical Director has concluded that the plan is correct in this case. The documentation does not support that Keytruda (Pembrolizumab) and Zoledronic acid are expected to be safe and effective and otherwise reasonable and necessary for the enrollee in this case based on the major drug compendia or by clinical research appearing in a Medicare approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the deluxe frames (V2020).

You asked the Plan to pre-approve the deluxe frames. You say that you broke your glasses two months ago and is not able to see. Without your glasses you are limited in doing things and have constant headaches and anxiety. The Plan denied your request. The Plan says this request exceeds the benefit limitation.

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. The Plan covers these services every two years. The records show your received eyeglasses. You will be eligible for the eyeglasses or contact benefit.

We looked at the file and the Plan's rules. The plan will pay up to $300 for eyeglasses (frames and lenses) or contact lenses every two years. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames have not been met. Therefore, we decided that the Plan does not have to pre-approve the deluxe frames (V2020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the emergency response system (S5161).

You asked the Plan to pre-approve the emergency response system. You say that you believe the Plan should cover this service. The Plan denied your request. The Plan says this is not a covered 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 emergency response system have not been met. The rules say that Telephone Alert Systems are not covered because emergency communications systems do not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to pre-approve the emergency response system (S5161).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.

You asked the Plan to pre-approve PET scan. You say that the enrollee is in severe pain and this test is to follow-up abnormal findings. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because conventional imaging with Computed Tomography (CT) scans are supported to monitor response to therapy.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the requested PET scan is not supported by guidelines in this setting. Conventional imaging with Computed Tomography (CT) scans are supported to monitor response to therapy. The enrollee does not have an indication for which a PET scan may be covered at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared
for in her condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's
medical needs are being met in the current acute setting.

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 physician
reviewer found that the enrollee was admitted to the acute hospital with respiratory failure. The enrollee has not
required prolonged mechanical ventilation. There is no documentation of intubation. The enrollee 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 she 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.

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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amiodarone tab 400mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.

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 Amiodarone tab 400mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and chiropractic manipulative treatment to be provided by a chiropractor.

You asked the Plan to pre-approve chiropractic services. You say that you need to have your spine realigned because your bones are not in a normal position. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because you do not meet the criteria for chiropractic treatment.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

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 chiropractic services Our reviewer says that you do not meet the criteria for coverage of chiropractic services. Our physician reviewer found the office notes reveal bone-on-bone disc space collapse and moderate retrolisthesis. Chiropractic notes reveal muscle guarding, muscle spasms, and a short right leg. However, the submitted findings to not reveal a subluxation as required per Medicare 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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit and chiropractic manipulative treatment to be provided by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient office visit and the x-ray.

You asked the Plan to waive the copayments for the outpatient visit and x-ray. You say that you were not
informed that there would be copayment charges for these services. The Plan denied your request. The Plan
says the cost of each service is clearly described in the Evidence of Coverage.

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 $45
copayment for urgently needed services and a $10 copayment for x-rays.

You have been asked to pay a total of $55 in copayments (a $45 copayment for urgently needed services and a
$10 copayment for x-rays). 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 copayments for the outpatient office visit
and the x-ray.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and root canal to be performed by an endodontist.

You asked the Plan to pre-approve the services. You say that these services are needed because you have pain and infection. The Plan denied your request. The Plan says dental services performed by an endodontist are not covered, and there is no listed benefit for root canals.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan covers certain dental services as long as they are provided by a participating general dentist. 

This is a two-fold denial. The requested services are to be performed by an endodontist, rather than a participating general dentist. Secondly, root canals are not listed as a covered benefit in the plan contract. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation and root canal to be performed by an endodontist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 50548 and 49000 are not supported.

In this case, the CPT Code Manual definition of code 50548 is laparoscopy, surgical; nephrectomy with total
ureterectomy. The definition of code 49000 is exploratory laparotomy, exploratory celiotomy with or without
biopsy(s) (separate procedure).

We find that CPT codes 50548 and 49000 are not supported in the medical record. Specifically, there is no
documentation of a surgical laparoscopy and nephrectomy with total urethrectomy to support code 50548.
There is no documentation of an exploratory laparotomy and exploratory celiotomy to support code 49000.
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 pay for the surgical services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.

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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the knee (73562) provided by an out of network (OON) provider.

You asked the Plan to pay for the x-ray. You say that this service was medically necessary and should be covered. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. This service was not urgent or pre-approved and could have been provided in network. The services were not referred by a contracted provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the knee (73562) provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.

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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services.