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 the enrollee's condition has stabilized and he is ready for discharge from the acute care hospital. You say that the enrollee needs transfer to an LTACH in order to regain maximum and prior level of functioning. You say that the enrollee also needs LTACH services in order to continue a multi-disciplinary approach to care.The Plan denied your request. The Plan says LTACH care is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a perirectal abscess. During draining of the abscess, the enrollee suffered a cardiac arrest. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. The enrollee is receiving wound care and participating in rehabilitative services. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two hundred (200) additional routine transportation trips.
You asked the Plan to pre-approve two hundred (200) additional routine transportation trips. You say that you need these rides to get to dialysis appointments. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty (30) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of thirty (30) trips for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve two hundred (200) additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultraviolet light therapy visits provided
from June 24, 2019 to November 19, 2019.
You asked the Plan to waive the copayments for dermatology visits. You say that you were told that the Plan
would pay for these treatments, and cost was a factor in your continuing with treatments. The Plan denied your
request. The Plan says the copayment amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40
copayment for each specialist visit. The ultraviolet therapy services you received are considered to be
dermatology specialist services, therefore the specialist copayment applies to each visit. For each visit, you
have been asked to pay the allowed amount of the claim because it is less than the $40 copayment for a
dermatology office visit.
Your total copayment responsibility is therefore $715.17.
You have been asked to pay less than $40 copayment for each dermatology visit. Dermatology visits 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 copayments for ultraviolet light therapy visits provided from June 24, 2019 to November 19, 2019.
Your complaint regarding receiving inaccurate information about the cost-share for these services is considered
to be a grievance. MAXIMUS Federal Services does not have the jurisdiction to address grievances. Please
contact the Plan for more information about your grievance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says none of the covered conditions are present in your case.
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 imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has no cardiovascular symptoms of chest discomfort or dyspnea on exertion with a good baseline activity level and no change in her exercise tolerance. She has no known prior history cardiovascular disease or angina and her EKG is essentially normal. Although she has risk factors for coronary artery disease, she is being treated with statin therapy and her diabetes is being managed. She meets none of the LCD criteria (Local Coverage Determination (LCD): Cardiovascular Nuclear Medicine (L33560) - Effective October 1, 2019) for nuclear stress testing in the absence of symptoms, CHF, prior MI or known CAD. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intermittent intravenous insulin therapy for the enrollee.
You asked the Plan to pre-approve these services. You say that this should be covered because of a network deficiency. The Plan denied your request. The Plan says that the requested service has been determined to be not reasonable and necessary for any indication.
The Plan must follow Medicare rules. Medicare rules say that Outpatient Intravenous Insulin Therapy regimen is nationally non-covered. Therefore, we decided that the Plan does not have to pre-approve intermittent intravenous insulin therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral appliance to treat sleep apnea (E0486).
You asked the Plan to pre-approve the oral appliance. You say that you are seeking to appeal a gap exception as there is no provider for E0486 in the enrollee's area. The Plan denied your request. The Plan says the records do not support medical necessity of the requested oral device. The oral device is not covered for out-of-network provider.
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 oral appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the original study was requested in 2013, for which there is no included record to confirm a face to face clinical evaluation at the outset of treatment. Some of the records noted the enrollee was
a denture wearer, but it was not made clear if this was referring to a partial or complete denture. The need to wear a denture suggests that an oral appliance may not be appropriate if there are an insufficient number of adequately supportive teeth which is not addressed in the record. The provider is not a Medicare DME provider. Although the claim noted there were no DME providers within a reasonable distance of the enrollee's location, this is not substantiated in the supplied records. Given the requirements under Medicare, where the DME must be provided by a Medicare DME provider. the criteria has not been 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 the oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve oral appliance to treat sleep apnea (E0486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health treatment from May 26,
2020 forward.
You asked the Plan to pre-approve continued inpatient behavioral health treatment. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are
not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continued inpatient behavioral health
treatment. Our reviewer says that the documentation does not support that the requested services are medically
reasonable or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient
psychiatric hospitalization on May 23, 2020 with Major Depressive Disorder, Recurrent, Moderate and Alcohol
Dependence with Intoxication, Unspecified. The enrollee presented with suicidal ideation. The enrollee wanted
to kill himself after the safe harbor homeless shelter refused him. The documentation supports that it was not
expected the enrollee would improve in a reasonable period of time beyond the dates in question as the enrollee
was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive or
unsafe behaviors. The enrollee was not showing any withdrawal behavior. Based upon review the records
provided, the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment
beyond the date in question of May 26, 2020 forward and could be treated in a lesser restrictive setting as the
enrollee was not showing any suicidal or homicidal ideation, being compliant with treatment while having no
auditory or visual hallucinations and was not showing any unsafe or abnormal behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient behavioral health treatment have not been met. Therefore,
we decided that the Plan does not have to pre-approve inpatient behavioral health treatment from May 26, 2020
forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (S9131) provided on November 27,
2019.
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says CPT code S9131 is not a payable code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9131 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9131 has a status code of I. This means that CPT code S9131 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the physical therapy services have not been
met. Therefore, we decided that the Plan does not have to pay for physical therapy services (S9131) provided
on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Sureclick.
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 records provided support the need for SNF care. The Plan denied your request. The Plan says daily therapy services are not reasonable and necessary, and lack an expectation of material improvement in reasonable time.
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 provided medical records do not indicate a need for skilled nursing services. The provided medical records do show that there is a need for skilled therapy services, but it is not indicated that there is a daily need. The provided medical records do not indicate that there is a need for inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate.
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 Dorzolamide/Timolol.You asked the Plan to pre-approve the Dorzolamide/Timolol. You say that the enrollee has been on Dorzolamide/Timolol since 2017 and her intraocular pressures are stable with this medication. You also say that you are requesting the enrollee remain on this medication.The Plan denied your request. The Plan says self-administered medications are not covered. The Plan also says that Dorzolamide/Timolol to be taken at home is not Medicare covered under the Part A or B benefits.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 Dorzolamide/Timolol.Benefits for the Dorzolamide/Timololmay 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Caris MI Profile genetic testing.You asked the Plan to pre-approve Caris MI Profile. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that biomarkers not addressed in the LCD or any other LCD will be considered not reasonable and necessary unless specifically covered by a national policy. 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 Caris MI Profile. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of adenocarcinoma of the lower third of the esophagus. The enrollee has stage IV disease, with liver involvement. The enrollee is receiving IV chemotherapy every 3 weeks. There is no family history of cancer. The enrollee's oncologist writes that the biomarker results will be used to help develop the most appropriate treatment plan for the enrollee. The LCD states that biomarkers not addressed in the LCD or any other LCD will be considered not reasonable and necessary unless specifically covered by a national policy. Esophageal cancer is not listed as a covered diagnosis in the LCD. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Caris MI Profile have not been met.Therefore, we decided that the Plan does not have to pre-approve Caris MI Profile genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan 550mg tablet.You asked the Plan to pre-approve Xifaxan 550mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Xifaxan 550mg tablet.Benefits for Xifaxan550mg tablet 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on December 16, 2019 to December 17, 2019.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 claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 hospital discharge services rendered on December 16, 2019 to December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Keytruda (Pembrolizumab) injection, 100mg/4ml.You asked the Plan to pre-approve the Keytruda injection. You say that the enrollee has intolerability of the medication and a progression of the disease. You also say that Ketruda is the best option for the enrollee at the time.The Plan denied your request. The Plan says the provided documentation does not show that the Keytruda is medically necessary.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 the Keytruda injection. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the use of Keytruda is FDA-approved for the enrollee's diagnosis. The reviewer found that based on the compendia, the listed use of Keytruda is not recommended due to the enrollee's prior immunotherapy. The reviewer found the documentation that was provided did not show a true progression as toxicities are likely to occur with Pembrolizumab also. Therefore the reviewer found that the Keytruda injection 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 the Keytruda injection have not been met.Therefore, we decided that the Plan does not have to pre-approve the Keytruda (Pembrolizumab) injection, 100mg/4ml.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 25, 2015 to February 28, 2015.You asked the Plan to pay for the skilled nursing services. You say that you had been consistently getting authorizations for the enrollee throughout the year, both prior and post to these dates of service. You also say that your home is usually vigilant about getting the necessary authorizations on file in a timely manner.The Plan denied your request. The Plan says the service was not medically necessary. The Plan also says that there is no evidence of a need for skilled nursing or rehabilitation services.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 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 provided from February 25, 2015 to February 28, 2015.