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

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September
26, 2019 to October 1, 2019; October 6, 2019 to October 9, 2019; and October 13, 2019 to October 25, 2019.
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied
your request. The Plan says skilled services were no longer necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 SNF care. Our reviewer says that daily
skilled services were not necessary. Our physician reviewer found the records do not show that the enrollee had
any identifiable skilled nursing or therapy service needs on the dates at issue. The enrollee also did not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pay for skilled nursing facility (SNF) care provided from September 26, 2019 to October 1, 2019; October 6,
2019 to October 9, 2019; and October 13, 2019 to October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic compression device provided on December 3, 2020.You asked the Plan to pay forthe pneumatic compression device (E0676). You say that the pneumatic compression device was medically necessary.The Plan denied your request. The Plan says items used for a preventative service or function are excluded from coverage under the Medicare DME benefit.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay forthe pneumatic compression device provided on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrolee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forHome Health Aide services provided on January 15, 2018 through February 15, 2019.You asked the Plan to pay for the Home Health Aide services. You say that you would like reconsideration because you are aging with chronic pain and your household income has diminished.The Plan denied your request. The Plan says there is no documentation that the services received were skilled care or therapy and claims were not filed within 12 months of the dates of service.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 rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. The record shows that a claim for the Home Health Aide services provided on January 15, 2018 through June 15, 2018 was not filed until February 15, 2020.. This means that more than one calendar year from the date of service had passed before a claim was filed. Additionally, the documentation submitted does not show that the services received were skilled care of therapy. No itemized statements or receipts were submitted to determine whether payment is due and the amount of service.Therefore, we decided that the Plan does not have to pay for Home Health Aide services provided on January 15, 2018 through February 15, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for an inpatient hospital stay provided from February 25, 2020 to March 13, 2020.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges due to quality of care concerns.The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for inpatient hospital care. The Plan says you must pay a $1,125 copayment for an inpatient hospital stay. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an inpatient hospital stay.Therefore, we decided that the Plan has to waive the copayment for an inpatient hospital stay provided from February 25, 2020 to March 13, 2020.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.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility(SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, the enrollee does not have daily skilled therapy or daily skilled nursing needs. The medical records do not show the enrollee meets a severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve chiropractic services. You say that you need a specific compression table
for treatment. The Plan denied your request. The Plan says there are in-network providers available for these
services.
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
chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 27, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.You asked the Plan to pre-approve the seat lift chair. You say that your chair portion of the seat lift broke and you need another one.The Plan denied your request. The Plan says the item in dispute is non-covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. 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 a seat lift chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you want coverage for a highly-skilled nursing
facility so the enrollee can get the care she needs to get better. You say if she goes to an IRF she will get help
from staff with memory techniques. The Plan denied your request. The Plan says based on Medicare
guidelines, the request for approval of an IRF admission does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 based on review of available records, the enrollee does not meet criteria for coverage
for an IRF admission. The enrollee is generally medically stable after a fall with no new neurological or
orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient
PMR physician three times per week or need for acute rehab nursing care. Currently the enrollee is at moderate
assist level with dementia. She cannot follow 2-step commands/ While the enrollee may benefit from
continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to
rehabilitation care. Her ability to retain the learned functional skills is limited due to dementia. Based on review
of the available records, admission to an IRF is not medically necessary based on enrollee's medical stability
and mental status.
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 7, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you had an annual wellness visit on the same date and you do not believe you should be charged for the laboratory services. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment per day, per provider, for in-network Medicare-covered laboratory services. You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the laboratory services provided on January 7, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Tempus xT genetic testing provided on January 13, 2020.
You asked the Plan to pay for genetic tests. You say that this testing was medically necessary and covered by
Medicare. The Plan denied your request. The Plan says that the denial of payment for these services is correct,
because these tests are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or outof-
network with the Plan. The documentation submitted does not include prior notice from the Plan that this
testing would not be covered. Without this information, we cannot determine whether the lab order made
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these
tests is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for Tempus xT
genetic testing provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLucentis for the enrollee.You asked the Plan to pre-approveLucentis. You say that this is medically necessary.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity fora step therapy exception.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 Lucentis. Our reviewer says that Lucentis is not medically reasonable and necessary for the enrollee in this case. There is no evidence that the enrollee is allergic to or intolerant of Avastin. There is no evidence that the enrollee has tried and not responded to Avastin. There is no documentation as to why Avastin would not be expected to be safe and effective for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Lucentis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met.Therefore, we decided that the Plan does not have to pre-approveLucentis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Indirect Decompression System.
You asked the Plan to pre-approve a Superion Indirect Decompression System. You say that the requested
Superion Indirect Decompression System is medically necessary. The Plan denied your request. The Plan says
the requested Superion Indirect Decompression System is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Superion Indirect Decompression
System. Our reviewer says that the requested Superion Indirect Decompression System is not medically
necessary. Our physician reviewer found this enrollee presents with a 3-year history of low back pain. The
current progress report indicated that the low back pain did not radiate. Functional limitations are noted due to
both knee and low back pain. Clear signs/symptoms of neurogenic claudication are not documented. There is
imaging evidence of severe stenosis at the L2/3, L3/4, and L4/5 levels. There is radiographic evidence of
scoliosis. He has failed to improve with reasonable and/or comprehensive conservative treatment. Under
consideration is a request for the Superion Indirect Decompression System. Current evidence based medical
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the
'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome
studies to support the use of this device for this enrollee's medical condition as discussed above. Additionally,
FDA indication include implantation of the Superion device at one or two adjacent lumbar levels in patients in
whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has severe
stenosis at the L2/3, L3/4, and L4/5 levels. There is no rationale why standard surgical decompression would
not be indicated. Additionally, FDA contraindications include scoliosis and osteoporosis. There is radiographic
evidence of an S-shaped scoliosis. There is no discussion indicating that a DEXA scan has demonstrated no
osteoporosis in this male. Therefore, this request for the Superion Indirect Decompression System is not
reasonable and medically necessary for this enrollee's medical condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Superion Indirect Decompression System have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Superion Indirect Decompression System.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the right hand and wrist.You asked the Plan to pre-approve a CT scan of the right hand and wrist. You say that the requested CT scan of the right hand and wrist is medically necessary.The Plan denied your request. The Plan says the requested CT scan of the right hand and wrist is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan of the right hand and wrist. Our reviewer says that the requested CT scan of the right hand and wrist is not medically necessary. Our physician reviewer found this enrollee presents with a history of chronic right moderate wrist and hand pain and tingling with gradual onset. There is no clear history of trauma. Clinical exam findings document full range of motion, no swelling or joint deformities, and no sensory deficits. Under consideration is a request for CT scan of the right wrist and hand. Current evidence based medical literature and guidelines would support initial evaluation of this enrollee's hand/wrist complaints with plain radiography. It was noted that CT scan was recommended to reduce Covid-19 risk, but there is no clear evidence that x-ray would place the enrollee at higher risk than CT scan. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to evidence-based literature and guidelines. Therefore, this request for CT scan of the right wrist and hand is not medically reasonable and 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 a CT scan of the right hand and wrist have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT scan of the right hand and wrist.