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 August 31, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services were not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the requested ambulance transportation was not medically reasonable and necessary. Our physician reviewer found that the medical records do not support the medical necessity of ambulance services to transport this enrollee to the hospital or a location to seek medical care. He demonstrated that he was able to ambulate outside of his home into the ambulance. There is no notation in the records of any alarming signs or red flags that would make this enrollee high risk to require ambulance services on this date of service. 

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.

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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a
colovesicular fistula. Your medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that this procedure would be beneficial.
The Plan denied your request. The Plan says this is not proven effective at this time.
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 Superion procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Superion spacer remains experimental. More research is needed to show safety
and efficacy of the device.
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 Superion procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care and wound debridement provided by an out-of-network provider on January 14, 2021.
You asked the Plan to pay for the nursing facility care and wound debridement. You say that the services were provided prior to obtaining authorization to avoid delay in care. You say that the services were medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says care must be received from network providers.
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 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 the nursing facility care and wound debridement provided by an out-of-network provider on January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on September 23, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you were told that you would owe a $0 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for X-rays provided at an outpatient hospital facility. You have been asked to pay the allowed amount of $75.73, which is less than the $110 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis for the enrollee.
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says the additional features of a custom fabricated prosthesis compared to a prefabricated silicone breast have not been established.
The Plan must follow Medicare rules. Medicare rules say that the additional features of a custom fabricated prosthesis compared to a prefabricated silicone breast have not been established. A custom prosthesis exceeds your needs according to Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pravastatin Sodium 40 mg tablet, 90-day supply.
You asked the Plan to pre-approve the self-administered drug. You say that this should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Pravastatin Sodium 40 mg tablet, 90-day supply.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the Vertiflex Superion Interspinous device is contraindicated in patients with spinal anatomy or disease that would prevent implantation of the device such as instability of the lumbar spine, such as spondylolisthesis and spinal deformity.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the vertiflex procedure. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for a diagnostic hearing service provided on October 5, 2020.
You asked the Plan to waive this cost share. You say that hearing tests should be no charge. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by your provider and the Plan contract agreement. Maximus overturned the Plans denial due to a lack of medical records in the file. The Plan requested a reopen and provided the medical records.
The Plan is correct in this case. 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 $10 copayment for outpatient diagnostic services. 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 $10 copayment charged for a diagnostic hearing service provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's rehabilitation needs are also not complex enough to require coordinated care between therapy disciplines.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for altered mental status and urinary tract infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 7, and core build up (D2950) for teeth # 7 and 10.

You asked the Plan to pre-approve the dental services. You say that tooth # 7 is fragile. You say that it could break before it is repaired. You also say that this should be covered. The Plan denied your request. The Plan says 1 crown is covered per year. The Plan says that the frequency limit for this service has been reached. The Plan also says that core build up is not listed as a covered service.

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 and crown is listed as a covered service, the frequency limit has been reached. The record shows that the Plan approved a crown for tooth # 10, thus exhausting the benefit. Additionally, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 7, and core build up (D2950) for teeth # 7 and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says there are in-network providers that would be able to meet your medical needs.
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 office visits to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
You asked the Plan to pre-approve the Superion surgery. You say that it is felt that this procedure would benefit the enrollee. The Plan denied your request. The Plan says this surgery remains experimental at this time.
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 Superion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion spacer remains experimental. More research is needed to show safety and efficacy of the device. 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 Superion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: 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. You say that you need extensive rehab to build back strength and balance in order to avoid another fall and further injury. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and for a urinary tract infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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.