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

We decided that the Plan does not have to pay for chiropractic services provided from September 25, 2020, through November 11, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered. Here are three exceptions: 1) The Plan covers emergency care or urgently needed services from an out-of-network provider. 2) If the enrollee needs medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, the enrollee can get this care from an out-of-network provider, with prior authorization from the Plan. 3) The Plan covers kidney dialysis services at a Medicare-certified dialysis facility when the enrollee is temporarily outside the Plan's service area.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from September 25, 2020, through November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on August 10, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record indicates that the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code but the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, G0483) provided on August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.

You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that the enrollee needs SNF services. The Plan denied your request. The Plan says there is no evidence that the enrollee has the degree of disability or medical complication that would require skilled nursing facility services.

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 a skilled nursing facility (SNF)admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 skilled nursing facility (SNF)admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on August 11, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the service at issue was billed with POS 81 for an independent laboratory, but the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not being treated with insulin 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not on insulin, and therefore do not require insulin adjustment. The requested service cannot be recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277) physician attendance and supervision of hyperbaric oxygen therapy, per session (99183) outpatient office visit (99213).
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you are hoping that the potential seriousness of osteoradionecrosis along with the doctor's demonstrated success with the patients he has treated will lead to approval in this particular situation. The Plan denied your request. The Plan says the enrollee does not meet the Medicare NCD medical necessity criteria and the policy does not recommend hyperbaric oxygen therapy for the enrollee's condition.
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 hyperbaric oxygen therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given the paucity of data on the use of hyperbaric oxygen for dental procedures after prior radiation, arguably it is not standard of care, though many would consider its use in select patients. Nevertheless, the LCD is explicit in what is covered. Hyperbaric oxygen is covered for soft tissue radionecrosis and not as a preventative measure for dental procedures after prior radiotherapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval (G0277) physician attendance and supervision of hyperbaric oxygen therapy, per session (99183) outpatient office visit (99213).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxaliplatin.

You asked the Plan to pre-approve Oxaliplatin. You say that the requested Oxaliplatin is medically necessary. The Plan denied your request. The Plan says the requested Oxaliplatin is 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 Oxaliplatin. Our reviewer says that the requested Oxaliplatin is not medically necessary. Our physician reviewer found the enrollee is diagnosed with HER2 positive gastric cancer. The requested use of Oxaliplatin is not FDA-approved for the enrollee's diagnosis. Approval is for patients that are HER2 negative, and this enrollee is HER2 positive. The requested use is not supported by any 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 Oxaliplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Oxaliplatin.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on November 1, 2019, to November 20, 2019.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that no one told you that would owe anything for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1-20. There is a $172 copayment per day for days 21-100 for skilled nursing facility (SNF) care/in-network. You have been asked to pay a $0 copayment per day for days 1-20. There is a $172 copayment per day for days 21-26 for a skilled nursing stay. The total amount you are being asked to pay is $1,032 ($172 x 6 days = $1,032 ($172 x 6 days = $1,032). A skilled nursing stay falls within the skilled nursing facility (SNF) care/in-network 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 a skilled nursing stay provided by a participating provider on November 1, 2019, to November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.

You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file. At issue is coverage for Opdivo (Nivolumab). The Maximus Physician Reviewer determined that the use of Opdivo is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The reviewer found that the documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee in this case. The Plan was unable to identify supporting literature and/or NCCN guidance for the use of single-agent Nivolumab in the treatment of metastatic neuroendocrine tumor (NET).

Our Medical Director says that the Plan is correct in this case. NCCN guidelines state that Ipilimumab and Nivolumab may be considered for the treatment of progressive locally advanced/metastatic disease following chemotherapy. The medical director did not find support for the use of Nivolumab monotherapy in the treatment of metastatic neuroendocrine tumor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like the dentures to be approved for coverage. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on August 14, 2019 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator to be provided by an out-of-network provider.
You asked the Plan to pre-approve the home ventilator. You say that the enrollee wishes to stay with your services due to the quality of care provided. The Plan denied your request. The Plan says the request is approved for one month to give time to change to an in-network provider.
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 the home ventilator to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on July 14, 2020.

You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges because you were not asked for a copayment at the time of service. 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 $25 copayment for outpatient surgery, including services provided at ambulatory surgical centers.

You have been asked to pay a $25 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for strapping provided on November 9, 2020.

You asked the Plan to waive the copayment for strapping. You say that you only saw a nurse practitioner not a physician and disagree with the charges.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 $25 copayment for specialist services. 

You have been asked to pay a $25 copayment for strapping. Strapping falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for strapping provided on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Medicare Part B injection provided on October 30, 2020.
You asked the Plan to reduce the coinsurance for the onabotulinumtoxina injection (J0585). You say that your coinsurance used to be less. The Plan denied your request. The Plan says you were charged the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Medicare Part B injection. the Medicare Part B injection falls within the Medicare Part B prescription drugs 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 reduce the coinsurance for the Medicare Part B injection provided on October 30, 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continuation of SNF care. You say that SNF care continues to be medically
necessary. The Plan denied your request. The Plan says rules for the continuation of SNF care have not been
met.

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 continuation of SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 83-yearold
female with Parkinson's disease, urothelial cancer, meningioma and atrial fibrillation admitted to the
hospital and then received SNF care. Following this SNF care, the beneficiary was at a maximal assist level
with functional mobility. There are no identifiable skilled nursing service needs and no identifiable skilled
therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a
daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has multiple degrees of spinal stenosis. Detailed documentation is not evident regarding flexion/extension films to evaluate for spinal instability (especially at this previously operated segment). Furthermore, scoliosis is noted and there is no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. The Superion spacer 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 a Vertiflex Superion spacer.