Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided on July 20, 2020.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve a portable ventilator. You say that this service is medically necessary. The Plan denied your request. The Plan says continuous positive airway pressure (CPAP) or bi-level CPAP therapy are not medically necessary and reasonable.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the requested device is not medically necessary and reasonable. Our physician reviewer found that you have obstructive sleep apnea, morbid obesity, and non-ischemic cardiomyopathy. There is a listed diagnosis of COPD, but spirometry results from 2018 are consistent with restrictive lung disease, not obstructive. You have been on CPAP in the past, but this resulted in emergence of central apneas. You had a successful BiPAP titration recently that showed effective treatment of the sleep disordered breathing at setting of 13/9 with backup rate of 10, with oxygen. There is no evidence of failure of BiPAP. The most recent clinical note indicates that BiPAP is being prescribed, not a ventilator. Medicare does not cover a ventilator when used as BiPAP. BiPAP would adequately meet this patient's needs. The denial of the ventilator is upheld. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99202) provided June 23, 2020.

You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for office visits. 

You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 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 an office visit (99202) provided June 23, 2020.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Evenity (J3111).

You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your
request. The Plan says that step therapy requirements have not been met.

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 Evenity. Our reviewer says that the
criteria for coverage of Evenity have been met. Our physician reviewer found the Plan requires a trial of Forteo
or Tymlos before they will approve the requested drug. However, while the enrollee has not tried and failed the
required drugs, the documentation supports that Forteo or Tymlos would be more likely to have adverse effects
for the enrollee in this case. Tymlos is not recommended in patients with existing hypercalcemia or those with
underlying hypercalcemic disorders. Forteo may cause hypercalcemia and should be avoided in patients with
preexisting hypercalcemia or hypercalcemic disorders.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have been met. Therefore, we decided that the Plan has to pre-approve
Evenity (J3111).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that the closest in-network chiropractor is 35 miles away and you are in too much pain to drive that far. The Plan denied your request. The Plan says the provider is out-of-network.
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 located within 20 miles, 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 the office visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Daliresp tablets.
You asked the Plan to pre-approve Daliresp tablets. You say that the enrollee has improved on this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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 Daliresp tablets.
Benefits for Daliresp tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500, A5512).
You asked the Plan to pre-approve diabetic shoes and inserts. You say that although the enrollee does not have diabetes, these items are medically necessary. The Plan denied your request. The Plan says these items are not covered for the enrollee's condition.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for his condition. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts (A5500, A5512).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 the step therapy requirement is not met.
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 services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer and osteopenia. He has not tried and failed the Plan's required drugs, alendronate and zoledronic acid. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the PureWick catheter (A9270).
You asked the Plan to pay for the PureWick catheter. You say that you would like reconsideration because the requested supply is medically necessary. The Plan denied your request. The Plan says the Purewick System is not directly related to the use of a covered urinary catheter or external urinary collection device; therefore, this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that use of the appropriate HCPCS code assures that accurate processing can be accomplished resulting in a proper claim determination and reimbursement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PureWick catheter have not been met. Specifically, per the PDAC, CPT code A9270 for the PureWick catheter is a non-covered item. Therefore, we decided that the Plan does not have to pay for the PureWick catheter (A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81286, 81407, 81408, 81479) provided on November 4, 2020.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81286, 81407, 81408, 81479) provided on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acromioplasty.
You asked the Plan to pre-approve acromioplasty. 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. 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 acromioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding the inherent medical necessity of this procedure. The appeal letter noted this procedure would be considered if the rotator cuff repair is not felt indicated during the diagnostic arthroscopy. There is limited published peer-reviewed literature that show including an acromioplasty with a rotator cuff repair for full-thickness cuff tears provides greater benefit. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the 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 acromioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve acromioplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom compression stockings
You asked the Plan to pre-approve the custom compression stockings. You say that these items are medically necessary. The Plan denied your request. The Plan says these are statutorily non-covered.
The Plan must follow Medicare rules. The rules say that custom compression stockings are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve custom compression stockings
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services.
You asked the Plan to pay for out of network physician services from August 13, 2019, to June 16, 2020. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus overturned the Plans denial because the required 2019 and 2020 Plan contract information was not submitted for review. The Plan requested a reopen and provided the required Plan contract information.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided from August 13, 2019, to June 16, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bed assist bar.
You asked the Plan to pre-approve a bed assist bar. You say that because of medical issues the enrollee needs a bed assist bar. The Plan denied your request. The Plan says a bed assist bar is not considered durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 bed assist bar.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 that the enrollee is a 72-year-old female who was admitted to the hospital after a fall. She was treated for multiple broken ribs on her left side. She was treated for difficulty breathing due to low blood oxygen levels. She was intubated and required mechanical ventilatory support. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve micro-needling and platelet rich plasma injections to
treat acne scarring.
You asked the Plan to pre-approve the services. You say that every time you look in the mirror you are
reminded of the trauma you went through when your acne advanced to a cystic stage causing disfiguring acne
scars. The Plan denied your request. The Plan says the services are not covered by Medicare or your health
plan. 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 services have not been met. The records show
you have scarring from cystic acne on your face. You claim that you find it difficult to look in the mirror
because this causes you mental anguish due to the appearance of your acne scarring. You do not have any
evidence of functional limitations. Your physician indicated to you that this would likely not be covered by
Medicare and had you sign a form acknowledging you would be responsible for the procedure if not covered
by Medicare insurance. The rules say, "cosmetic surgery or expenses incurred in connection with such surgery
is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except
when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the
improvement of the functioning of a malformed body member." Therefore, we decided that the Plan does not
have to pre-approve micro-needling and platelet rich plasma injections to treat acne scarring.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 29, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. Maximus overturned the Plans denial based on the Plan contract provided. The Plan requested a reopen and provided the correct Plan contract the enrollee is a member of.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on June 4, 2020.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional claim information. The Plan states that the claim image shows the provider NPI submitted is for a physician. The records show the enrollee received ambulance Services from an NPI for a medical center. The Plan states the services were billed inappropriately with the incorrect taxonomy code to allow payment. The Plan stated the provider needed to bill with the appropriate taxonomy for ambulance land transport.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error with the taxonomy code. Based on this information, we decided that Medicare rules for coverage of this transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on June 4, 2020.