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

We decided that the Plan does not have to pay for physician services provided on February 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that the there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician services provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the slumberbump purchased on March 20, 2020.

You asked the Plan to pay for the slumberbump. You say that the doctor recommended this for sleep apnea, and you are due $70.82. The Plan denied your request. The Plan says this is not a covered service under the wellness benefit. The Plan also says that this was not purchased from a contracting durable medical equipment supplier to be covered under that benefit.

The Plan rules say that a slumberbump is not considered a covered benefit under the Wellness Allowance and it was not purchased from a contracting durable medical equipment supplier to be covered under that benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the slumberbump have not been met. Therefore, we decided that the Plan does not have to pay for the slumberbump purchased on March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 4, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips.
You asked the Plan to pre-approve thirty (30) additional routine transportation trips. You say that you need additional transportation for physical therapy appointments. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
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 fifty-two (52) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan does not have to cover routine transportation above the benefit maximum benefit of fifty-two (52) routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dalfampridin 10mg Tablets.
You asked the Plan to pre-approve Dalfampridin. You say that Dalfampridin is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dalfampridin 10mg Tablets.
Benefits for Dalfampridin 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for hospital services including an inpatient admission provided from
March 3, 2021, through March 6, 2021.
You asked the Plan to pay for hospital services including an inpatient admission. You say that you had a medical emergency and went to the hospital for medically necessary care. You say the physicians in the emergency department evaluated you and admitted you inpatient. The Plan denied your request. The Plan says that authorization was not obtained.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for hospital services including an inpatient admission by a contract provider. The file does not show that the Plan provided notice that hospital services including an inpatient admission would not be covered prior to the services being provided. Under Medicare rules, this means hospital services including an inpatient admission is considered approved by the Plan. Therefore, we decided that the Plan has to pay for hospital services including an inpatient admission provided from March 3, 2021, through March 6, 2021.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic CGM device (K0554) provided on March 13, 2021.
You asked the Plan to pay for a CGM. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The document provided as proof of delivery applies to items provided on another date of service. The medical records provided do not document a diagnosis that supports the medical necessity of the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a therapeutic CGM device (K0554) provided on March 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the medical records provided support the need for care in a SNF. The Plan denied your request. The Plan says SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gastric Bypass Surgery.
You asked the Plan to pre-approve Gastric Bypass Surgery. You say that you have tried medication to help lose weight and had to be taken off of it and you qualify for the surgery. The Plan denied your request. The Plan says the provider you are requesting has not written an order and deemed you not appropriate for the procedure.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and (3) been unsuccessful with medical treatment for obesity. We looked at the file and Medicare rules. No clinical information was received to establish medical necessity.
Based on this information, we decided that Medicare rules for coverage of Gastric Bypass Surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Gastric Bypass Surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genomic sequence analysis panel (81455) provided on February 3, 2021.

You asked the Plan to pay for genomic sequence analysis panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. The testing at issue is unlikely to impact therapeutic decision-making and is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for a genomic sequence analysis panel (81455) provided on February 3, 2021.
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 October 19, 2020.

You asked the Plan to pay for these services. 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.

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 October 19, 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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. Our physician reviewer found your medical conditions are stable and you have are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a diagnostic colonoscopy.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a diagnostic colonoscopy is covered when specific 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a personal history of malignancy and meets the criteria for immunocompromised based on this and her advanced age. Stool studies have failed to reveal a cause for diarrhea and her symptoms persist. The colonoscopy is therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve a diagnostic colonoscopy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the esophagogastroduodenoscopy (upper GI endoscopy) you had at an ambulatory surgical center on March 3, 2021.
You asked the Plan to waive the deductible and copayment for the upper GI endoscopy. You say that you do not believe you should have to pay both a copayment and a deductible for the same service. The Plan denied your request. The Plan says you were charged this deductible and copayment 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 $50 copayment after the deductible for outpatient procedures and services, including endoscopies. The Plan contract also says that you have a $250 deductible that applies to outpatient services. You have been asked to pay your $250 deductible and a $50 copayment for the upper GI endoscopy. Your Evidence of Coverage states that you are required to pay the deductible before the Plan will pay anything towards your care. It also states that once your meet this deductible, the Plan will begin to pay their share and you will pay your share (your copayment). So, your Evidence of Coverage explicitly advises you that a copayment will apply in addition to this deductible. 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 deductible and copayment for the esophagogastroduodenoscopy (upper GI endoscopy) you had at an ambulatory surgical center on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain ceramic crowns for teeth numbers 7, 8, 9, and
10 for the enrollee.

You asked the Plan to pre-approve porcelain ceramic crowns for teeth numbers 7, 8, 9, and 10. You say that
these dental services are medically necessary. The Plan denied your request. The Plan says based on the dental
records; the criteria needed for coverage of these services are not met. Maximus overturned the Plans denial.
The Plan requested a reopen and stated that the dental criteria from the Plan clearly states authorizations for
crowns will not meet coverage criteria when crowns are being done primarily to treat attrition, abrasion,
erosion or abfraction.

The Plan is correct in this case. 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 condition of the teeth for which the
crowns were requested did not meet the required criteria for the approval of crowns. Therefore, we decided that
the Plan does not have to provide coverage for porcelain ceramic crowns for teeth numbers 7, 8, 9, and 10 for
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not
support the ability to tolerate an intensive therapy program.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that you were admitted to the acute care hospital for the Coronavirus. Your medical problems are stable. The
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided to the enrollee on March 25, 2021.

You asked the Plan to pay for these services. 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 telehealth care and the records provided do not support that the services billed are covered by Medicare.

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 mental health care provided to the enrollee on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
You asked the Plan to pay for 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levemir.

You asked the Plan to pre-approve Levemir. The Plan denied your request. The Plan says the drug is not covered under the medical benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Levemir. 

Benefits for Levemir may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.