Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 LTACH services have not been met.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 6, 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 by the member's primary care physician.
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 January 6, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on September 20, 2019.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the x-ray services was not filed until March 31, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on September 20, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on April 12, 2021.

You asked the Plan to pay an additional amount for a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images. You say that you want the Plan to reimburse you for these services. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate therefore no additional payment can be made.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee needs this due to many commodities. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the placement of an implant after breast reconstruction provided on March 9, 2020.
You asked the Plan to waive the copayment for the placement of an implant after breast reconstruction. You say that you disagree with the charges because you received the bill over a year after the services were received. You also state that the Plan should be responsible for the charges because your original implants were recalled. 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 $40 copayment for wound care services and a $350 copayment for all other services provided in an outpatient
hospital facility. You received the placement of an implant after breast reconstruction provided at an outpatient hospital facility on March 9, 2020. The placement of an implant after breast construction is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for the placement of an implant after breast reconstruction. The placement of an implant after breast reconstruction 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 the placement of an implant after breast reconstruction provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve a knee scooter. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
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 a knee scooter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the requested scooter is safe for the patient to use. There is no objective neuromuscular exam or cognitive exam indicating the patient can safely use this device or why the patient is unable to use crutches. 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 knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary for the enrollee.
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 and the reopen request. At issue is coverage for Keytruda. The
Maximus Physician Reviewer determined that the requested use of Keytruda is FDA-approved for the
enrollee's diagnosis when PD-L1 positive. The reviewer found that if progression occurs several months or
years after the last dose of PD-1 or programmed cell death ligand 1 (PD-L1) blockade, re-challenge may be
attempted, as some responses have been reported. The reviewer also found that the documentation supports that
the requested drug is safe and effective for this enrollee. Therefore, the reviewer found that Keytruda is
medically reasonable and necessary. The Plan argues the medical records show the enrollee's disease
progression is documented to have occurred immediately following the 3-month treatment with Imfinzi, only 5
days after the last dose was provided. The Plan states that review of the NCCN guidelines note that "If
progression on PD-1/PD-L1 inhibitor, using a PD-1/PD-L1 inhibitor is not recommended."
The medical records show the enrollee is a 79-year-old woman who was diagnosed with stage IIIA non-small
cell lung cancer in 2019. The enrollee was treated with radiation therapy, followed by treatment with Paclitaxel
and Carboplatin. The enrollee was treated with Imfinzi (Durvalumab) from January 30, 2020 through April 23,
2020. A PET scan on April 28, 2020 showed progression of disease following PD-L1 therapy. The enrollee
was subsequently treated with Gemcitabine, combined with Cisplatin and Docetaxel. Our Medical Director has
concluded that the Plan is correct in this case. Per NCCN Clinical Practice Guidelines in Oncology, Non-Small
Cell Lung Cancer, Version 5.2021-June 15, 2021, if there is progression of disease on a PD-1/PD-L1 inhibitor,
using a PD-1/PD-L1 inhibitor is not 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the therapeutic exercises (97110) and the physical therapy evaluation (97161) provided from April 8, 2021, through April 26, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $35 copayment for each in-network Medicare-covered physical and speech therapy service.
You have been asked to pay $210 ($35 copayment x 6) for the in-network Medicare-covered physical therapy services provided. 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 copayments for the therapeutic exercises (97110) and the physical therapy evaluation (97161) provided from April 8, 2021, through April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on March 29, 2021.

You asked the Plan to pay for an occlusal guard. You say that the service is medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an occlusal guard (D9944) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device purchased on March 1, 2021.
You asked the Plan to pay for a CPAP device. You say that you believed you would not need authorization because medical necessity was established for you previous device. The Plan denied your request. The Plan says this was purchased from a supplier that is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the supplier at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device purchased on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a face-down positioning device provided on September 25,
2020.
You asked the Plan to pay for face-down positioning device. You say that you had to rent this chair for your
eye surgery. The Plan denied your request. The Plan says the denial of payment for this item is correct, because
this item is considered precautionary and can be used for purposes other than the treatment of an illness or
injury.
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 pay for a face-down positioning device provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for Chronically Ill (SSBCI) (S9986).
You asked the Plan to pre-approve the special benefit. You say that you are requesting re-evaluation of your case for the supplemental benefits. The Plan denied your request. The Plan says the enrollee does not meet any of the criteria established to receive the special supplemental benefits for the chronically ill for 2021.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special benefit have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve the Special Supplemental Benefits for Chronically Ill (SSBCI) (S9986).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99308 provided on July 16, 2020.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were not billed with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. We find that CPT code 99309 is not supported in the medical record. Specifically, this code was billed with a primary, first-listed diagnosis code of F01.51 (Vascular dementia with behavioral disturbance). This diagnosis code cannot be used as a primary, first-listed diagnosis code. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99308 provided on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table.

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 precautionary-type equipment is considered nonmedical in nature and not covered. 

We looked at the file and Medicare rules. The requested inversion table is not covered by Medicare because it is a precautionary device that does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve an inversion table.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 24, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that prior authorization was not obtained.
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 lab work provided on August 24, 2020 by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested provider.

You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says you must receive your care from a network provider except for certain exceptions. The Plan covers emergency care or urgently needed services that you get from an out-of-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested provider.