Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is not a candidate for oral bisphosphonates or Reclast. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan requires a trial of oral bisphosphonates and zoledronic acid before it will approve Prolia.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of oral bisphosphonates and zoledronic acid. You have indicated that the enrollee is not a candidate for oral bisphosphonates or intravenous Reclast; however, the enrollee does not have a confirmed diagnosis of osteoporosis for which Prolia would be indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implant removal services identified with code D6100.
You asked the Plan to pre-approve dental implant removal services. 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 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 pre-approve dental implant removal services identified with code D6100.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical dental extractions (41899).
You asked the Plan to pre-approve surgical dental extractions. You say that this is necessary because the enrollee is in pain. The Plan denied your request. The Plan says this is 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 pre-approve surgical dental extractions (41899).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar decompression and fusion after recent fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 surgery services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested services are a medical necessity. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested services are not medically necessary.
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 that LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 the enrollee 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 Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342).
You asked the Plan to pre-approve the scaling and planing. You say that the enrollee needs this service in order to bring them back to proper form and function. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 pre-approve the periodontal scaling and root planing (D4342).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 12 fractions of intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has prostate cancer with
extension to the seminal vesicle and possible pelvic node involvement. The Plan has approved 28 fractions of
IMRT. The requested 12 further fractions are reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to preapprove
12 fractions of intensity modulated radiation therapy (IMRT).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on March 17, 2020.
You asked the Plan to pay for the physician service. You say that the services that were provided on the date of
service are not hospice related. You also say that the services were medically necessary. The Plan denied your
request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is
revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering
services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 14, 2020. The services in question were provided
before the end of that month. Additionally, the record shows that the enrollee re-enrolled in hospice on March
19, 2020. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on
March 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit received on June 5, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the claim has been processed correctly per
your plan benefits.
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 provider at issue is not enrolled in the Medicare
program. Since the services were for emergency services, the plan did pay the maximum allowable fee rate to
the provider. Since you received care from a provider who is not eligible to participate in Medicare, you are
responsible for the remaining cost for the services received. Therefore, we decided that the Plan does not have
to pay for the emergency department visit received on June 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 30,
2020.
You asked the Plan to waive the copayment for the ER visit. You say that your symptoms were getting better,
so you asked the admission desk to cancel the visit. You say that a $1,000 bill for talking to admission and
getting vitals checked is excessive. The Plan denied your request. The Plan says the copayment applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment per visit for emergency care.
You have been asked to pay $73.64, which is less than the standard $90 copayment for the ER visit. The ER
visit falls within the "Emergency care" benefit category. The records show you received ER services. 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 ER visit provided on November 30, 2020.
Appeal type: Surgery
Decision: Favorable

We have decided to dismiss the Plan's request to reopen the case because it does not meet Medicare rules for a reopening. The Plan submitted their own physician review of this case in which they disagree with our decision. Our Medical Director looked at the case file and the reopen request. At issue is coverage for a Watchman Device (Percutaneous left atrial appendage closure). The Maximus Physician Reviewer determined that the enrollee has recurrent documented symptomatic PAF, and cannot take long-term anti-coagulation owing to recurrent iron deficiency anemia which was symptomatic and required transfusion. His "CHA2DS2VASc" score is 3 and he should be anti-coagulated based on this to decrease his risk of embolic stroke. As he has had recurrent anemia on anti-coagulation which cannot be rectified with GI interventions, he would meet clinical criteria for a left atrial occluder device based on published guidelines.
The Plan argues that patient care team did not include pre-operative and post-operative team members, and two independent non-interventionalists. The medical records show the enrollee is a 73-year-old man with a history of symptomatic paroxysmal atrial fibrillation, hypertension, and recurrent symptomatic anemia.
Our Medical Director has concluded that this appears to be a difference of opinion among medical experts.
When making medical necessity determinations, Maximus physician reviewers consider many factors including peer reviewed literature, practice guidelines, and current standards of care. Determinations of medical necessity are tailored to the individual patient and their unique clinical scenario. In this case, a Maximus Physician Reviewer, with appropriate expertise and qualifications, rendered an unbiased and well-considered opinion. The medical review was appropriate and well-supported by documentation. There is sufficient documentation that the enrollee is under the care of a cohesive multidisciplinary team of medical professionals. Thoughtful, qualified experts can and often do, disagree about interpretations of case file evidence and its application to coverage determinations. The fact that the health plan disagrees with our expert's opinion is not in itself sufficient grounds for reversing the determination in this case. We find no evidence of error in this case and we are therefore dismissing the request to reopen. Our decision remains that the Plan has to pre-approve a percutaneous left atrial appendage closure (Watchman Device) (93355, 33340).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs are not complex and he does not need an intensive team for 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for surgical repair of an ankle fracture. His medical problems are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. 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 the famotidine injection services coded S0028 provided on June 1, 2020.
You asked the Plan to pay for the famotidine injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 S0028 is injection, famotidine, 20 mg. We find that CPT code S0028 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the famotidine injection services have not been met. Therefore, we decided that the Plan does not have to pay for the famotidine injection services coded S0028 provided on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says 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 documentation provided does not support admission to a LTACH. The enrollee is
receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider.

You asked the Plan to waive the copayment for an injection. You say that this is way too high. You say that your old Plan paid for all your pain management services. 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 $100 copayment for outpatient surgery/in-network.

You have been asked to pay a $100 copayment for an injection. The correct copayment has been applied to the services that were provided. An injection falls within the outpatient surgery/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 an outpatient surgery provided by a participating provider.