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

We decided that the Plan does not have to pay for the ambulance services provided on November 18, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee currently has multiple medical bills. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260).
You asked the Plan to pre-approve osseous surgery. You say that the services are necessary. The Plan denied
your request. The Plan says the requested service 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. Therefore, we decided that the Plan does not have to pre-approve
osseous surgery (D4260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 85060 provided on December 1, 2020.
You asked the Plan to pay for CPT code 85060. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of CPT code 85060 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service described by current procedural terminology (CPT) code 85060 provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve admission to an IRF. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF admission.
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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records in order to determine if the enrollee meets Medicare criteria for IRF admission. The Plan states their determination was based on medical records; however, the file only contains one hand-written progress note. The Plan has not shown that sufficient medical records were reviewed to determine medical necessity. Therefore, we decided that the Plan has to pre-approve admission to an inpatient rehabilitation facility (IRF).
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda,100 mg/4 ml (pembrolizumab).
You asked the Plan to pre-approve Keytruda. You say that you have treated the enrollee heavily. You say that the enrollee shows expression of PD-L1. You also say that you would like to pursue the option of pembrolizumab. The Plan denied your request. The Plan says that the criteria has not been met.
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 Keytruda. Our reviewer says that the requested drug, Keytruda, is not medically necessary. Our physician reviewer found the requested use of Keytruda FDA-approved for the enrollee's diagnosis when PD-L1 positive. The reviewer found that if progression occurs several months or years after the last dose of PD-1 or programmed cell death ligand 1 (PD-L1) blockade, rechallenge may be attempted, as some responses have been reported. The reviewer also found that the documentation supports that the requested drug is safe and effective for this enrollee. Therefore, the reviewer found that Keytruda is 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda,100 mg/4 ml (pembrolizumab).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that skilled nursing is not an appropriate safe level of care at this time. The Plan denied your request. The Plan says the enrollee does not have complex medical or intensive rehab needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that the enrollee was admitted to the acute care hospital for weakness and falls. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Movantik.
You asked the Plan to pre-approve Movantik. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Movantik.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. You say that the requested service is medically necessary. The Plan denied your request. The Plan says that the requirements for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy is subject to the criteria listed in the Medicare rules section. 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 Gelsyn-3. Our reviewer says that the requested service is medically reasonable and necessary. Our physician reviewer found that this 67-year-old man has bilateral osteoarthritis documented with weight bearing knee x-rays. There is also documentation of intra-articular steroid injection and the patient is doing physical therapy at this time. The request meets the criteria of the LCD and is 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 Gelsyn-3 have been met. Therefore, we decided that the Plan has to pre-approve Gelsyn-3 (J7328).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that lower levels of care lack the daily physician
oversight necessary to manage the enrollee's conditions. The Plan denied your request. The Plan says the
enrollee does not require supervision by a rehab doctor, or aggressive therapies by an intensive team.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 physician reviewer found
that the enrollee is at a minimal assist level for rolling, moderate assist for sitting up, and maximal assist for
scooting. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician
evaluation.
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: 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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee requires additional short-term acute care services to continue basic wound care, which can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that you that need SNF care since are unable to get around your house to do everyday things to care for yourself. You say that you live alone so the care that you would get with home health skilled nursing would not be sufficient to help you to recover and you have no one that can help care for you. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge, and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional routine transportation trips.
You asked the Plan to pre-approve 15 additional routine transportation trips. You say that the member will need additional transportation trips for an upcoming surgery. The Plan denied your request. The Plan says the benefit for routine transportation has been exhausted.
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 48 one-way 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 member has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 15 additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study(93971) provided to the enrollee on September 9, 2020 under Claim A.

You asked the Plan to pay Claim A. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan stated that Claim A denied because the Plan had already paid for this service under another claim. The Plan states the NPI website shows that both providers are listed as diagnostic radiology specialists and both providers work within the same professional practice or group. The Plan states the correct billing of this service needed to include modifier -59 to establish a separate and distinct service was provided. 

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met.

Therefore, we decided that the Plan does not have to pay for the extremity study(93971) provided to the enrollee on September 9, 2020 under Claim A.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Peripheral Nerve Stimulation (PNS) using a SPR Sprint device, for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says percutaneous electrical nerve field stimulation (PENFS) is unproven and not medically necessary due to insufficient evidence of efficacy.
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. physician reviewer found peripheral nerve stimulation devices are not yet proven to be helpful for the enrollee's conditions to help support this request. Therefore, this request for such will be considered not medically necessary based on currently available evidence. 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 Peripheral Nerve Stimulation (PNS) using a SPR Sprint device, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power elevation system or upgraded electronics.
You asked the Plan to pre-approve a power seat elevation feature (E2300) or the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 3 power wheelchair with tilt, power elevation system, and upgraded electronics. The Plan denied your request. The Plan says the approved power option comes with its own switches and a power elevation system is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevation feature 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. The power tilt seating system has its own switch. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power elevation system or upgraded electronics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like this denture to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve a maxillary partial denture (D5225).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is still too sick to go to a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that you were admitted to the acute hospital for atrial fibrillation, abscess and necrotizing fasciitis. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 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 pre-approve radiation oncology consultation to be performed at an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the provider is not in-network and there are network providers available to provide the 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 radiation oncology consultation to be performed at an out-of-network provider.