Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forprophylaxis -adult (D1110) and periodic oral evaluation -established patient (D0120) provided on June 17, 2019,by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this service is covered at your selected primary care dentist office only and you have not chosen a primary care dentist.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. This service is covered at your selected primary care dentist office only and you have not chosen a primary care dentist.Therefore, we decided that the Plan does not have to pay forprophylaxis -adult (D1110) and periodic oral evaluation -established patient (D0120) provided on June 17, 2019, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation -problem focused (D0140) provided on May 10, 2019 by a non-participating provider.You asked the Plan to pay forthe dental services. You say that you were having pain in your tooth when biting down. You state the dentist did not find anything wrong during the visit.The Plan denied your request. The Plan says you made a call to the health plan dental vendor on May 10, 2019 to verify benefit coverage for the services received and you were advised on that call thatprocedure code D0140 is not a covered benefit.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140) provided on May 10, 2019 by a non-participating provider.
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. The Plan denied your request. The Plan says IRF admission is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 that 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
documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or
nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and
occupational therapy, but the enrollee does not require this on an intensive rehabilitation facility therapy
program level 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that finger stick testing messes up your hand and bruises your fingers. The Plan denied your request. The Plan says you are not on an insulin pump or insulin injecting.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file, and Medicare rules. Your physician has confirmed you are not on insulin. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department (ED) visit (99281) and hand x-ray (73130) provided on May 16, 2019 by the medical center.
You asked the Plan to pay for the ED visit and hand x-ray. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says that based on Medicare billing criteria, the claim was denied correctly.
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. 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 states the services were not billed appropriately; however, they do not specify what the billing issue or statutory exclusion was. The Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for an emergency department (ED) visit (99281) and hand x-ray (73130) provided on May 16, 2019 by the medical center.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. The Plan denied your request. The Plan says this 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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician reviewer found that this spacer remains experimental. More research is needed. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that 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 documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee does not require this and the documentation does not support the patient can tolerate this on an intensive rehabilitation facility therapy program level 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chronic care management services provided on August 30, 2019.
You asked the Plan to waive the copayment for chronic care management services. You say that you did not see the physician and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you disagree with the charges.
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 $5 copayment for primary care doctor visits. You have been asked to pay a $5 copayment for chronic care management services. Chronic care management services fall within the physician/practitioner services, including doctor's office visits 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 chronic care management services provided on August 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee cannot receive the level of care needed using home health care. You say that the enrollee also has cognitive impairment due to dementia. You say that, if she utilizes home health and has exercises to do when they are not with her, then it is likely that she would forget to do them, which may hinder her healing process. The Plan denied your request. The Plan says the medical records do not show that the enrollee did daily skilled nursing care or skilled therapy for 1-3 hours per day for at least 5 days per week.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee continues to receive wound care and has pain which needs to be assessed and treated. The enrollee requires oversight of her medical conditions and medication management. The enrollee is at risk for further episodes of cellulitis. The enrollee has not returned to her prior level of function. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee has skilled needs, but they are not needed on a daily basis. The enrollee is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The enrollee is receiving care that can be provided by her non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The enrollee's condition would not be expected to deteriorate with services provided on a less than
daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pump and leg garment (E0652 and E0667).
You asked the Plan to pre-approve a Flexitouch pump and leg garment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says there has been no documented trial of conservative therapy demonstrating failed response to treatment of an E0650 or E0651 for 4 weeks which is required under Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare guidelines say that in order for a PCD coded as E0652 to be covered, a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651 is required. The file does not show that the enrollee has received a four week trial demonstrating a failed response to treatment with an E0650 or E0651. Based on this information, we decided that Medicare rules for coverage of a Flexitouch pump and leg garment have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pump and leg garment (E0652 and E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to you by an out-of-network provider from June 3, 2019, to June 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were provided by an out-of-network 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 has network providers available who can provide the 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 chiropractic services provided to you by an out-of-network provider from June 3, 2019, to June 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325).
You asked the Plan to pre-approve these injections. You say that the preferred medications Orthovisc and Monovisc are not provided within the clinic as they are not available. The Plan denied your request. The Plan says the preferred viscosupplements are Orthovisc and Monovisc. The requested drug is subject to a step therapy requirement. Documentation and/or medical records were not received supporting the medical necessity for a 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 these injections. Our reviewer says that the patient does not meet criteria for coverage. Our physician reviewer found the medical records provided do not indicate that the patient has tried and failed the required drugs. Additionally, the medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
You asked the Plan to pre-approve the POV. You say that you need the scooter to get around town as you are not able to walk a long distance and sometimes a short distance. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 POV have not been met. It is not medically necessary for completing daily activities of life inside the home. The records show that you are able to walk inside your home independently. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99201) to be provided by out of network provider.
You asked the Plan to pre-approve office visits. You say that the doctor has completed two lumbar spine surgeries on your back. You say that you just found out that you have two screws that are loose, and one screw broken. You feel because that doctor put the hardware into you back it would be beneficial if he did the evaluation for continuity of care. You also says that you have degeneration in your thoracic spine and you are okay seeing a plan provider because this concern is new. The Plan denied your request. The Plan says it is understood that, given the choice, you would prefer to have continuity of care with your prior spinal surgeon. The Plan says in this case, as required by your contract with us an in-network spinal surgeon could evaluate your condition and could provide the needed medical or surgical care in most cases and/or could arrange for appropriate specialty care.
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 pre-approved care. 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 office visits (99201) to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July
27, 2019 through August 13, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the stay was medically
necessary. The Plan denied your request. The Plan says the stay is a new admission.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care provided from July 27, 2019 through August
13, 2019. You are asked to pay a $370 copayment per day, for days 1-5 of your inpatient hospital care.
Therefore, you are responsible for a $1,850 copayment for the inpatient hospital care. 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 inpatient hospital care provided from July 27, 2019 through August 13, 2019.
MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern.
MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care
concern to the appropriate Quality Improvement Organization for further review.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you need additional SNF care to regain your strength. The Plan denied your request. The Plan says there are no longer any daily skilled service needs.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee continues to receive wound care and requires oversight of his medical conditions and medication management. The enrollee is at risk for secondary complications of immobility such as pressure ulcers and contractures. The enrollee has not returned to his prior level of function. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, the enrollee has reached a functional plateau consistent with his current orthopedic precautions. The enrollee has skilled needs, but they do not need to be provided on a daily basis. The enrollee is able to transfer and perform bed mobility without hands-on assistance. There are limited goals at a wheelchair level of function until the enrollee's precautions can be advanced. The enrollee is receiving care that can be provided by his non-skilled care givers with periodic skilled oversight and modification of care plan if needed. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Pushtronex for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by the plan.
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 Repatha Pushtronex for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.