Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for level 3 custodial care visits (99336 x3) and brief emotional assessments (96127 x3) provided June 25, 2020, to August 20, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. Maximus partially overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says this was a rest home visit. The Plan states this type of screening or evaluation is only covered once per year. The Plan states the enrollee has exceeded this benefit for 2020.
The Plan is correct in this case. Medicare does not cover this type of evaluation. The Plan covers one evaluation per year in a primary care office setting. The records show the enrollee exhausted this benefit. Therefore, we decided that the Plan does not have to pay for level 3 custodial care visits (99336 x3) and brief emotional assessments (96127 x3) provided from June 25, 2020, to August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a spa/Jacuzzi provided August 30, 2020, to September 22, 2020.
You asked the Plan to pay for a spa/Jacuzzi. You say that these services were medically necessary. The Plan denied your request. The Plan says the records do not support the necessity of the provided services.
The Plan must follow Medicare rules. Medicare rules say that whirlpool bath equipment is covered if patient is homebound and has a (standard)condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. We looked at the file and Medicare rules. The records provided do not indicate that you are currently homebound. Based on this information, we decided that Medicare rules for coverage of a spa/Jacuzzi have not been met. Therefore, we decided that the Plan does not have to pay for a spa/Jacuzzi provided August 30, 2020, to September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital level of care for infusion services

You asked the Plan to pre-approve inpatient hospital care. You say that this hospital facility does not accept observation care for this procedure. The Plan denied your request. The Plan says that the denial of authorization for inpatient level of care is correct, because you do not meet the criteria for inpatient care and have been approved for observation care instead.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 inpatient hospital care. Our reviewer says that you meet the Medicare criteria for inpatient hospital level of care. Our physician reviewer found a request has been made for an inpatient admission for the management of migraine headaches. During the course of this admission, you would be treated with dihydroergotamine (DHE) and a "cocktail" of other parenteral drugs. Such stays generally last longer than 2 midnights (most are for roughly 5 days). As you require medically necessary hospital care that is expected to span 2 or more midnights, the inpatient admission would be considered 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 inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve inpatient hospital level of care for infusion services

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the oral exam (D0120), the bitewing x-rays (D0274), the prophylaxis (D1110), the topical application of fluoride varnish (D1206), and the unspecified preventive service (D1999) provided on September 2, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you were originally scheduled for cleanings at a different dental office for April 2020. You say that when Covid-19 hit, that office closed, and you returned to Minnesota. You also say that you would like an out of network exception to be made due to Covid-19. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network dentists may bill you for any amount greater than the payment made by the Plan to the provider. The Plan says that topical application of fluoride varnish is not listed as a covered service. The Plan also says that you did not contact the plan prior to the date of service to verify benefits and provider eligibility.
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 the oral exam, bitewing x-rays, and prophylaxis are listed as covered, out of network dentists may bill you for any amount greater than the payment made by the Plan to the provider. Additionally, the topical application of fluoride varnish and the unspecified preventive services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the oral exam (D0120), the bitewing x-rays (D0274), the prophylaxis (D1110), the topical application of fluoride varnish (D1206), and the unspecified preventive service (D1999) provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple power options and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options and accessories. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says the request is not reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power options will not be covered if the patient does not meet coverage criteria for a power tilt and recline seating system. 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 Group 3 power wheelchair with multiple power options and accessories. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found that there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living (MRADLs) and that cannot be helped by the use of a walker, cane, or manual wheelchair due to significant weakness and unstable balance. You can safely operate a power mobility device and have a covered indication that would require a group 3 powered wheelchair as specified in the Medicare rules. However, there is no documentation that you satisfy the basic requirements for the power seating system as there is no documentation of high risk status for skin breakdown. There is no documentation that you have a high risk for development of a pressure ulcer and are unable to perform a functional weight shift; or that you utilize intermittent catheterization for bladder management and are unable to independently transfer from the wheelchair to bed; or that the power seating system is needed to manage increased tone or spasticity. 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 Group 3 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple power options and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of fosaprepitant and palonestron hydrochloride (Medicare Part B antiemetic drugs).

You asked the Plan to pre-approve Part B drugs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because these drugs are not 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 Part B drugs. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of fosaprepitant and palonestron. Our physician reviewer found the requested use of these drugs is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Abraxans is low emetogenic risk, and the enrollee has not failed standard antiemetics. The requested use is not supported by major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Part B drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve use of fosaprepitant and palonestron hydrochloride (Medicare Part B antiemetic drugs).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 pain related to bilateral
knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records
do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 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 Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you are not getting the help you need and would like a second opinion. The Plan denied your request. The Plan says the services are available 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 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 a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and extraction provided on August 18, 2020 by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray and extraction. You say that you were under the impression that these services would be covered. The Plan denied your request. The Plan says services are required to be performed by a contracted dentist.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and extraction provided on August 18, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network acupuncturist.
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 services are available 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 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 a referral to an out-of-network acupuncturist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
You asked the Plan to pre-approve 60 additional routine transportation trips. You say that you need additional routine transportation trips to make your dialysis appointments. The Plan denied your request. The Plan says this benefit 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 60 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 you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin (CPT code J9045), Pemetrexed (CPT Code J9045) with Keytruda (pembrolizumab) (CPT code J9271), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the use of Keytruda in the enrollee's case requires use as a single agent for deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) disease. The Plan states the requested combination regimen is not supported for use in colon cancer.
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 medication. Our physician reviewer found the requested drugs are not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin (CPT code J9045), Pemetrexed (CPT Code J9045) with Keytruda (pembrolizumab) (CPT code J9271), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second custom socket insert (L5683) and a second test
socket (L5620).
You asked the Plan to pre-approve a second custom socket insert and a second test socket. You say that the
enrollee needs these items. The Plan denied your request. The Plan says one of each of the requested items was
previously approved.
The Plan must follow Medicare rules. Medicare rules say that that codes L5681 and L5683 are for use only
with the initial issue of a custom fabricated socket insert. Additional inserts (either custom fabricated or
prefabricated) provided at the time of initial issue or replacement socket inserts are coded L5673 and L5679,
whichever is applicable. Socket replacements are considered reasonable and necessary if there is adequate
documentation of functional and/or physiological need.
We looked at the file and Medicare rules. The record shows that the Plan approved one unit each of L5683 and
L5620 at the time of the initial request. A second initial insert cannot be approved with code L5683, and there
is no justification provided documenting the need for a second test socket. Based on this information, we
decided that Medicare rules for coverage of a second custom socket insert and a second test socket have not
been met.
Therefore, we decided that the Plan does not have to pre-approve a second custom socket insert (L5683) and a
second test socket (L5620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a compression reduction kit.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that a compression reduction kit is noncovered because it does 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 a compression reduction kit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorper.
You asked the Plan to pre-approve Prochlorper. You say that this is medically necessary. 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 Prochlorper.
Benefits for Prochlorper 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 the Volara device, oscillation and lung expansion therapy.
You asked the Plan to pre-approve the Volara device, oscillation and lung expansion therapy. You say that there is clinical value and proven necessity of the system for the enrollee. The Plan denied your request. The Plan says there is no documentation that the Volara device that combines both therapies is superior to the individual devices.
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 Volara device, oscillation and lung expansion therapy. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the Volara device is considered not medically necessary, because there is insufficient evidence that it is effective in the treatment of bronchiectasis or COPD. This device combines positive end-expiratory pressure, oscillation of airflow, and nebulization of medication. High-frequency chest wall oscillation is considered effective in airway clearance in patients with bronchiectasis and is medically necessary when other treatments have failed. The Volara device does not use external oscillation; its oscillation of airflow, rather than the chest wall, has not been clearly demonstrated to be effective in airway clearance. And there is no convincing evidence of benefit when combined with positive pressure and nebulization. The denial 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 the Volara device, oscillation and lung expansion therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara device, oscillation and lung expansion therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5298) received January 8, 2021, from the
out-of-network provider.
You asked the Plan to pay for the hearing aid. You say that you were told you could purchase hearing aids from
this provider. The Plan denied your request. The Plan says you must purchase your hearing aid from a Plan participating
provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only purchased from a Plan-participating hearing vendor.
We looked at the file, and the Plan's rules. You did not purchase the hearing aid from a Plan-participating
hearing vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5298) received
January 8, 2021.