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

We decided that the Plan does not have to pre-approve a total knee replacement with a custom knee implant for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical necessity for the requested total knee arthroplasty with the customized Conformis implant is not supported by evidence based medical guidelines or peer-reviewed literature. The requested implant is considered experimental and investigational. Evidence of large volume long term studies reflecting any significant ultimate outcome differences( regarding function and pain relief) are not evident in the medical literature at large. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested total knee replacement with (Conformis) custom knee implant is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee replacement with a custom knee implant for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan does have to make additional payment for the addition of a tooth to existing partial denture and extraction We decided that the Plan does not have to make payment in full for the addition of a tooth to existing partial denture and extraction.

You asked the Plan to pay more for the addition of a tooth to existing partial denture and extraction. You say that you were not advised that the treating provider was OON. The Plan says that you signed a financial policy and was advised of the costs before the services were rendered. The Plan also says that your benefits were applied correctly.

We decided that the Plan has to make additional payment for the addition of a tooth to existing partial denture and extraction.

The Plan follows Medicare rules. Medicare rules say that 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 does not say in clear and accurate terms how much you should expect to pay for the addition of a tooth to existing partial denture and extraction when received from an OON provider. You reasonably believed that the Plan would cover 50% of the amount claimed of these services according to your EOC. Therefore, we decided that the Plan has to make additional payment for the addition of a tooth to existing partial denture and extraction.

We also decided that the Plan does not have to make payment in full for the addition of a tooth to existing partial denture and extraction.

The Plan follows Medicare rules. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b).

The contract clearly states that you are responsible for a 50% coinsurance for the cost of the addition of a tooth to existing partial denture and extraction according to your EOC. You must pay 50% of the amount claimed for these services. Therefore, we decided that the Plan does not have to make payment in full for the addition of a tooth to existing partial denture and extraction.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for urgent care services (including COVID-19 testing).

You asked the Plan to pay for the services. You say that this should be waived because COVID-19 testing was received. The Plan denied your request. The Plan says that the copayment was applied 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 $65 copayment for urgently needed services.

You have been asked to pay a $65 copayment for the services. The services fall within the urgently needed 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 has to pay for urgent care services (including COVID-19 testing).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on September 30, 2020.
You asked the Plan to pay for this transport. You say that due to the destination exceptions granted for Covid-19, this transport should be covered. The Plan denied your request. The Plan says Medicare criteria for non-emergent transport were not met. Maximus agreed with the Plan. You requested a reopen based on the destination exception.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for ambulance transport. Maximus determined that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. The medical records show the enrollee is a 69-year-old woman who was transported by ambulance to a physician's office for follow-up of an Emergency Department visit the week prior. It is noted that the enrollee was unable to ambulate due to muscle atrophy from bed-confined status. The enrollee was transferred to the stretcher and was transported to the office. While CMS has temporarily expanded the list of allowable destinations for ambulance transports to include physician's offices, the general coverage rules for ambulance transport still apply. The documentation does not support that the another means of transport, such as a stretcher van, was contraindicated for the enrollee at the time of transport. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee in this case. There are not sufficient grounds for reversing the determination 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 this transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport provided to the enrollee on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a participating provider on August 14, 2020.
You asked the Plan to waive the deductible for an outpatient surgery. You say that you do not think it is fair to be charged a hospital fee for this. The Plan denied your request. The Plan says the correct deductible amount has been applied.
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 there is a $750 deductible for outpatient hospital services/surgery. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services/surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient hospital services/surgery. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on August 14, 2020. The total amount you are being asked to pay is $245.40. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a participating provider on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on November 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you submitted the medical records and proof of timely filing for a retro-authorization. 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. 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 nursing facility care provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane injection (J9264).

You asked the Plan to pre-approve Abraxane. You say that the requested treatment is medically necessary. The Plan denied your request. The Plan says rules for approval of Abraxane are not met as the request is for an off-label and not medically accepted use.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Abraxane. Our reviewer says that the requested item/service is not medically necessary and reasonable. Our physician reviewer found that the requested use of Abraxane is not FDA-approved for the enrollee's diagnosis. Furthermore, the use is not supported by one of the major drug compendia or by clinical research that appears 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 Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane injection (J9264).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0220, D1999, D0210).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says these services are not covered under your dental 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 pay for dental
services (D0220, D1999, D0210).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided by an out of network (OON) provider.

You asked the Plan to pay for the ultrasound. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 had network providers available to provide the imaging services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636).

You asked the Plan to pre-approve radiofrequency ablation. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for approval of radiofrequency ablation are not met.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is covered when certain criteria are met as detailed in the "Medicare rules" section of this letter.

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 radiofrequency ablation. Our reviewer says that the requested is considered not medically necessary or reasonable. Our physician reviewer found that the enrollee had a set of diagnostic MBBs but there is no documentation of the level and duration of pain relief. The lack of documentation precludes meeting the Medicare coverage criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64635, 64636).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an OON provider.

You asked the Plan to pay for lab test. You say that this was medically necessary and related to your diagnosis.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.

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 medical services provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee has stage four wounds and needs dialysis. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for treatment of acute metabolic encephalopathy secondary to sepsis and associated with acute kidney injury (AKI), non-ST elevated myocardial infarction (NSTEMI), and rhabdomyolysis. The documentation does not support long term enteral feeding access has been established and is stable. Feeding tube placement occurred on March 20, 2021. There is no documentation provided necessitating admission to a LTACH. 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 he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2020 to September 14, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided should support the medical necessity of the services in dispute. The Plan denied your request. The Plan says that inpatient level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the emergency room documentation and studies clearly demonstrate the presence of an obstructed bile duct by evidence of dilatation and elevated bilirubin. The documented plan at the time of admission demonstrates an expectation of a hospital stay expected to span two midnights. Th elements of the applicable Medicare rule are satisfied. Coverage for the inpatient stay is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2020 to September 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97140, 97110, G0283) provided October 19, 2020.
You asked the Plan to waive the copayment for the physical therapy services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $40 copayment for outpatient physical therapy services. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services fall within the outpatient physical therapy 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 physical therapy services (97140, 97110, G0283) provided October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on September 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician visit. You say that you would like the claim reviewed and reprocessed with the provider as in network. 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. 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 physician visit provided on September 15, 2020 by an out of network (OON) provider.