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

We decided that the Plan does not have to pre-approve interspinous process decompression device (IPD).

You asked the Plan to pre-approve interspinous process decompression device (IPD). You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 interspinous process decompression
device (IPD). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found you were being treated for spinal stenosis, lumbar region
with neurogenic claudication. You have almost no pain with sitting and severe pain with standing and walking.
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for your medical condition.
FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in enrollees
with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to
L5. You have severe disc space narrowing at L3-4, L4-5 (moderate narrowing at L5-S), and would not meet
FDA indications. Therefore, you do not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of interspinous process decompression device (IPD) have not been met. Therefore,
we decided that the Plan does not have to pre-approve interspinous process decompression device (IPD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided by an out of network provider.

You asked the Plan to pay for the ophthalmology services. You say that this doctor is a network provider and is the only practitioner that does the procedure you need. The Plan denied your request. The Plan says you do not have out-of-network coverage.

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 the ophthalmology services provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops, 5%.

You asked the Plan to pre-approve the Xiidra drops. You say that the enrollee needs these drop to help the cornea and conjunctiva lubricated. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Xiidra drops, 5%.

Benefits for the Xiidra drops 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you have tried every other medication, but get very ill and you cannot take them. The Plan denied your request. The Plan says this is covered under the Part D benefit, not under Part B.

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 and will be brought to the office for administration. 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 Prolia.

Benefits for Prolia 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care.

You asked the Plan to pay for the SNF services. You say that the services provided to the enrollee are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF care is not medically necessary. The Plan says that  therapy was given two times or less per week. The Plan also says that this does not satisfy the Medicare guidelines for requiring skilled therapy on a daily basis.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF services provided have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and resin-based composite provided on September 23, 2020.

You asked the Plan to pay for the preventive procedure and resin-based composite. You say that you do not recall being advised that your tooth repair insurance was dropped. The Plan denied your request. The Plan says these services are not covered.

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 the preventive procedure and resin-based composite provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the kidney stone fragmentation service (50590) performed in an outpatient setting.

You asked the Plan to waive or reduce the copayment for the outpatient procedure. You say that you believe the cost is too high for this service. The Plan denied your request. The Plan says services and procedures performed in an outpatient hospital setting are subject to a $350 copayment.

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 $350 copayment for outpatient hospital procedures and services.

You have been asked to pay a $350 copayment for the outpatient procedure. The kidney stone fragmentation procedure took place in an outpatient hospital setting and falls within the outpatient hospital procedures and services 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 or reduce the copayment for the kidney stone fragmentation service (50590) performed in an outpatient setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.

You asked the Plan to pay for the pneumatic compression device. You say that this device was used during your surgery. The Plan denied your request. The Plan says a pneumatic compression device used for the purpose of prevention of venous thromboembolism is a preventative device and excluded from coverage.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
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 records provided support the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 received oral medications, had stable vital signs, was alert with confusion, and was treated for a UTI. The enrollee received physical therapy in the acute hospital, was dependent for functional mobility and care, and had difficulty following commands. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) supplies (A7027, A7034, A7030, A7035).

You asked the Plan to pre-approve the CPAP supplies. You say that these devices are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says coverage criteria for continued CPAP coverage has not been met.

The Plan follows Medicare rules. Medicare rules say that continued coverage for a CPAP device and related accessories requires you use the device 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 

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 CPAP supplies. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the reviewed documentations indicates that a CPAP compliance report from December 15, 2020, to January 13, 2021 was provided. The member used the CPAP 7% of the days (2/30) for an average of 21 minutes daily. The percentage of day's usage greater than 4 hours was 7%. Therefore, the review has determined that the enrollee does not meet the LCD criteria based on the medical records to support this request. 

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 CPAP supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) supplies (A7027, A7034, A7030, A7035).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve KESIMPTA auto-injectors.

You asked the Plan to pre-approve KESIMPTA auto-injectors. You say that the enrollee has tried numerous
medications for her MS and each one has been ineffective or not tolerated. You say that the enrollee stared out
on office and company samples and has been doing well with the medication. You say that the enrollee's
symptoms have reduced, and she is starting to feel better. You say that stopping this medication would be
detrimental to her health, and she would end up in a total MS relapse and in the hospital. The Plan denied your
request. The Plan says the medication in dispute falls under Part D coverage, but the enrollee has no Part D
pharmacy benefit under this contract.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 KESIMPTA auto-injectors.

Benefits for KESIMPTA auto-injectors 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) scan services.

You asked the Plan to pre-approve the CT scan. You say that a recent CT of the chest reveled new progressive pulmonary lung nodules. You say that the enrollee has had increasing transaminitis and hypercalcemia. You say that, given these findings, it is of utmost importance that the enrollee undergo a CT with contrast of the abdomen and pelvis for further evaluation and to look for a possible primary site of lymphoma. The Plan denied your request. The Plan says that the clinical information provided does not describe the results of an ultrasound. The Plan says that the guidelines for coverage of a CT scan have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee smokes and has progression of pulmonary nodules on a CAT scan of the chest from February 15, 2021. In addition, the enrollee has transaminitis and hypercalcemia concerning for underlying malignancy. A CAT scan of the abdomen and pelvis is requested to further evaluate for metastatic disease. An ultrasound of the liver would not be enough to evaluate for disease outside of the liver. The requested service is 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 10, 2020 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. The Plan says that the member's primary care physician did not refer 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 August 10, 2020 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 periapical x-ray provided on November 24, 2020.

You asked the Plan to pay for the dental service. You say that you were having tooth pain. You say that the dentist took an x-ray. You say that you had no way of knowing that the x-ray that was taken would not be covered. You also say that the charge for this service should be paid. The Plan denied your request. The Plan says 1 set of full mouth series, bitewing x-rays, or panoramic x-ray is payable per calendar year. The Plan also says that periapical x-ray is not listed as a covered service.

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 the periapical x-ray provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace provided on August 7, 2020.

You asked the Plan to pay for the brace. You say that the treating physician is allowed to provide exams via telecommunications. The Plan denied your request. The Plan says the claim was processed correctly.

The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is only covered under certain medical indications. 

We looked at the file and Medicare rules. The file shows that the record provided was based on a phone conversation. The records do not include previous records of the enrollee's clinical course, extent of functional limitations, or other therapeutic interventions. There are insufficient medical records of the enrollee's medical condition to substantiate the necessity of the brace. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the back brace provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 10, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 physician's services. 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 physician's services provided on January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (Shingles) vaccine.

You asked the Plan to pay for vaccine. You say that you were told that this would be covered by the Plan. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this vaccine is
not covered by Medicare Part B and the Plan does not administer your Medicare Part D benefits.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccine. The Plan
follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to vaccine. Therefore,
we decided that the Plan does not have to pay for a Zoster (Shingles) vaccine.

Benefits for vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.

Your complaint regarding receiving inaccurate information about the coverage for this service is considered to
be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please
contact the Plan for more information about your grievance.