Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the records provided you are receiving nursing, physical therapy and home health aide services through a home health agency already and these services do meet the definition of home health aide services. Based on the medical records provided there is no documentation that the services being provided are inadequate or that the agency would not be able to increase services if needed, thus the additional requested services through a different agency do not appear to be reasonable and necessary for treatment of your illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 has network providers available who can provide 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 an office visit provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs incontinence supplies that require a substantial financial outlay. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement tub/whirlpool.
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
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 replacement tub/whirlpool.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit when in a
skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that a power wheelchair is being requested for use in a SNF or hospital. Therefore, we decided
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch blocks at three levels.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that injections are covered when the above frequency
criteria are met.
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 injections. Our reviewer says that
the requested injections are not medically reasonable and necessary. Our physician reviewer found that the
request does not meet the LCD criteria both in terms of duration and degree of pain relief and exceeds the
utilization limit of 2 levels.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar medial branch blocks at three levels.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids that include the initial molding.
You asked the Plan to pre-approve the hearing aids. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids that include the initial molding.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says services can be safely received in other settings, such as a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. Our physician reviewer found the enrollee's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. He is currently in an outpatient setting and does not require an acute hospital level of care. He is ambulating and transferring independently and does not require an intensive rehabilitation therapy program. The enrollee is limited by the severity of his residual neurological deficits and has already had several courses of acute level rehabilitation. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. The enrollee's care can be appropriately provided through ongoing home-based care or at an SNF level if his condition deteriorates again. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the medical condition must be of a level of complexity that requires an intensive and coordinated interdisciplinary approach including physician visits at least three times weekly.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on December 4, 2019.
You asked the Plan to waive the copayment for emergency care. You say that you feel that you were discharged too soon. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on December 4, 2019.
Your quality of care concerns have been handled separately by the health plan. Medicare does not permit MAXIMUS to make a decision on this type of complaint.
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 this is medically necessary. The Plan denied your request. The Plan says you do not require active and ongoing therapeutic intervention of multiple therapy disciplines at an IRF level of intensity.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The
Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interrogation device evaluation provided on November 18, 2019.
You asked the Plan to waive the copayment for the interrogation device evaluation. You say that you were not charged this amount for your previous visit. You say that you shouldn't be liable for the bill. The Plan denied your request. The Plan says the copayment applied correctly.
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 $60 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a $60 copayment for the interrogation device evaluation. The interrogation device evaluation 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 the interrogation device evaluation provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Core Build Up (D2950) and a Porcelain/Ceramic Crown (D2740).
You asked the Plan to pre-approve the Core Build Up and the Porcelain/Ceramic Crown. You say that the items are medically necessary. The Plan denied your request. The Plan says the requested Core Build Up and Crown are not covered benefits.
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 Core Build Up (D2950) and a Porcelain/Ceramic Crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external catheter.
You asked the Plan to pre-approve the requested item. You say that you urinate without warning. The Plan denied your request. The Plan says you do not have permanent urinary incontinence.
The Plan follows Medicare rules. Medicare rules say that urological supplies are only covered under certain medical indications. 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 requested item. Our physician reviewer found that the records do not indicate that you have permanent urinary incontinence. You have poor mobility due to morbid obesity. This is not causing permanent incontinence. With weight loss, mobility should improve and result in resolution of the incontinence. Therefore, the requested services are not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve an external catheter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180) and
full mouth debridement (D4355).
You asked the Plan to pre-approve the comprehensive periodontal evaluation and full mouth debridement. The
Plan denied your request. The Plan says comprehensive periodontal evaluation is not a covered benefit. The
Plan also says that the enrollee received a comprehensive periodontal evaluation within the last year and
exhausted their full mouth debridement 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, comprehensive periodontal evaluation
(D0180) is not among those covered under this benefit. The contract also clearly states that full mouth
debridement (D4355) cannot be performed on the same day or less than 1 Calendar year after an evaluation
(D0120, D0150). The record shows that the enrollee received a comprehensive oral evaluation (D0150) on
March 5, 2020 and the enrollee's full mouth debridement benefit has been exhausted. Therefore, we decided
that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180) and full mouth
debridement (D4355).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup manual wheelchair (K0004).
You asked the Plan to pre-approve the manual wheelchair. You say that you would like reconsideration because the member's current wheelchair is too small and she feels unsafe. The Plan denied your request. The Plan says backup wheelchairs are not covered by Medicare.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Additionally, Medicare does not cover backup wheelchairs. Therefore, we decided that the Plan does not have to pre-approve a backup manual wheelchair (K0004).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve swimming lessons.
You asked the Plan to pre-approve these services. You say that the lessons have helped with your swollen foot. The Plan denied your request. The Plan says the services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are swimming lessons, which fall under the category of gym benefits and exercise lessons. The plan has approved aquatic therapy as an alternate, Medicare-covered service. Therefore, we decided that the Plan does not have to pre-approve swimming lessons.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic office visits (99203) and electrical stimulation (97014) provided from January 10, 2020 to January 17, 2020.
You asked the Plan to pay for chiropractic office visits and electrical stimulation. You say that you were referred for these services by your doctor. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic office visits (99203) and electrical stimulation (97014) provided from January 10, 2020 to January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that the enrollee is known by this provider. 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 orthopedic surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve root canal therapy.
You asked the Plan to pre-approve root canal therapy. You say that every time you bite down the tooth cut your mouth. The Plan denied your request. The Plan says that this is not covered by your 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 root canal therapy.