Persius/hicric huggingface dataset:
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 from January 31, 2021, to February 28, 2021.

You asked the Plan to pay for out of network services. You say that these services should be covered by the Plan. 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 from January 31, 2021, to February 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that Gel-One (J7326) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has tried and failed Monovisc but has not tried and failed Orthovisc. Our reviewer also found that there is no indication that Orthovisc would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cook Fenestrated Branched Stent Graft with three branches.
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is an investigational service.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a 6 cm distal aortic arch and thoracoabdominal dissection involving the brachiocephalic, left common carotid, and left subclavian arteries. The record documents that the provider has stated that the repair procedure would utilize a device that is currently under clinical investigation and is not currently approved. The case file indicates that the enrollee is not in a clinical trial. The device is considered experimental and investigational. The requested device is not medically reasonable or necessary, as defined by Medicare rules, for the enrollee's clinical situation.
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Cook Fenestrated Branched Stent Graft with three branches.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

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 services at issue in this appeal. 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 services provided by an out-of-network provider on July 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex ultrasound of the neck for the enrollee.

You asked the Plan to pre-approve a duplex ultrasound of the neck. You say that this testing is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met as the enrollee
is asymptomatic. Maximus overturned the Plans denial stating while there are no symptoms present for
vascular disease, the enrollee is at risk due to a history of peripheral vascular disease and continues to smoke.
The Plan requested a reopen and stated Medicare does not cover this type of testing for screening purposes with
no present symptoms of disease or illness.

The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests
for asymptomatic patients done for the "possibility" of disease are not covered. While it is understood the
previous vascular issues and the smoking were concerns, there were no symptoms present warranting this scan.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pre-approve a duplex ultrasound of the neck ordered for the enrollee as a screening.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you cannot function on your own. The Plan denied your request. The Plan says this 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you do not have documented skilled nursing or therapy needs. You are ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan.

You asked the Plan to pre-approve a low dose CT scan. You say that this CT scan 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 applied the incorrect criteria.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that low dose CT
scans are covered only when there are no signs or symptoms of lung cancer. This would include a history of
lung cancer. The medical records show that you have a previous history of lung cancer. Therefore, criteria
needed for this imaging are not met. Therefore, we decided that the Plan does not have to pre-approve a low
dose computed tomography (CT) scan.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 enrollee continues to receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

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. The rules say that Botox is covered for specific indications only. 

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 an ischemic ulceration of the left ring finger with pain and uncontrolled diabetes. The records do not support that the enrollee has a condition for which treatment with Botox is covered. The Botox is therefore 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 Botox.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 3, 2020, to November 6, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you are being overcharged for physical therapy. 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 $275 copayment for days 1-4 for inpatient hospital care.

The medical records show that you had an inpatient hospital stay from November 3, 2020, to November 6, 2020. Therefore, you are responsible to pay a $275 copayment for days 1-3 (November 3, 2020, to November 5, 2020). $275 (copayment) x 3 (inpatient days) = $825. 

You have been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 3, 2020, to November 6, 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 enrollee's needs would be best met in the IRF setting. The Plan denied your request. The Plan says the criteria for this level of care are not met.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit (99285) and drainage of abscess, cyst, hematoma, vestibule of mouth (40800) provided November 24, 2020.

You asked the Plan to pay for the emergency visit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these diagnoses are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99285 and 40800 is not supported in the medical record. Specifically, the claim was billed with diagnosis codes R079 for chest pain and K047 for periapical abscess without sinus. A corrected claim must be resubmitted as it needs a corresponding diagnosis code. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) and drainage of abscess, cyst, hematoma, vestibule of mouth (40800) provided November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or CNA (S9122) provided on January 8, 2021.
You asked the Plan to pay for the HHA or CNA. You say that the enrollee needs assistance on every level of medical care. The Plan denied your request. The Plan says the request for payment did not include sufficient information to allow for the correct processing of the claim.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage have not been met. The record does not include sufficient information to determine whether payment is due or the amount of payment. Specifically, the record does not include clinical information or a description of the billed services. Therefore, we decided that the Plan does not have to pay for the HHA or CNA (S9122) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses, progressive lenses, polycarbonate lenses and UV lenses provide don March 12, 2021.

You asked the Plan to pay for eyeglasses and lenses. You say that you would like a reconsideration of your copayment amount. The Plan denied your request. The Plan says the claim was processed according to your 2021 benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan contract says that you have a $200 allowance once per year to use towards the purchase of eyeglasses or contact lenses. 

We looked at the file and the Plan's rules. The records show that the price for your glasses and lenses was $419. The provider subtracted your $200 allowance which left a balance of $219. The provider then applied a 20% off discount, which came to $43.80. This brought your total balance due to $175.20. Based on this information, we decided that the Plan's rules for coverage of eyeglasses and lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2020), progressive lenses (V2781), polycarbonate lenses (V2784) and ultraviolet lenses (V2755) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental implant services received on March 3, 2021.

You asked the Plan to pay for the dental implant services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services received are 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. Certain dental services are only covered when you have been continuously covered under the dental plan for more than 24 months. Review of the file shows that you received these dental benefits on January 1, 2021. Twenty four (24) months had not passed since you became effective with the dental plan. Therefore, we decided that the Plan does not have to pay for the dental implant services received on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for sensors for use with a continuous glucose
monitor.

You asked the Plan to provide coverage for this equipment. You say that you are blind, and this equipment is
medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria are not met
because you are not treated with insulin. Maximus overturned the Plans denial and stated that this equipment
would be beneficial due to the presence of blindness.

The Plan requested a reopen and stated that unfortunately, being treated with insulin is a Medicare requirement
for coverage of this equipment and its supplies.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees with diabetes use insulin with at least
three daily injections. The provider has confirmed, and the medical records confirmed that you are not treated
with insulin. Based on this information, we decided that Medicare rules for coverage of this equipment have
not been met. Therefore, we decided that the Plan does not have to provide coverage for sensors for use with a
continuous glucose monitor.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 enrollee is still on a ventilator and has a pneumothorax. The enrollee is not clinically stable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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 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.