Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Privigen injections (J1459) provided November 27, 2020 and December 28, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was 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 20% coinsurance for Part B drugs. You have been asked to pay a 20% coinsurance (a total of $1,257.73) for the injections. The injections fall within the Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Privigen injections (J1459) provided November 27, 2020 and December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on August 4, 2020.
You asked the Plan to pay for the outpatient clinic visit. You say that authorization was needed but inadvertently not obtained. You say that the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but 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 the outpatient clinic visit provided by an out-of-network provider on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Group 3 Power Wheelchair and accessories
for the enrollee.
You asked the Plan to provide coverage for a Group 3 Power Wheelchair and accessories. You say that the
requested power wheelchair is medically necessary. The Plan denied your request. The Plan says the specific
coverage criteria for a Group 3 Power Wheelchair and related accessories are not met. Maximus partially
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for a Group 3 Power Wheelchair. Our Medical Reviewer looked at the case file. Our reviewer says that the
medical records show the enrollee has a mobility deficit, but the documentation does not show it consistently
interferes with activities of daily living inside the home. The enrollee is noted to be independent with bed
mobility, dressing, grooming, eating, mod independent with toileting and independent but needs excessive time
with transfers. The records show the enrollee can ambulate with walker up to 50 feet per the DME evaluation.
The DME evaluation indicating that the requested Group 3 power wheelchair is not appropriate, but a
repair of battery and joystick of her current wheelchair is appropriate. The documentation does not support that
the enrollee is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder
management or has increased tone or spasticity. The enrollee does not have a cast, brace, musculoskeletal
condition that needs an elevating leg rest. There is no evidence of significant edema of the lower extremities on
the medical office visit progress notes. There is no evidence that the patient requires a reclining back on the
wheelchair. The enrollee does not meet the criteria for the power seating system, combination tilt and recline,
with power shear reduction and power elevating leg rests.
Based on this review and the Medicare coverage criteria, the records do not show the enrollee has a mobility
limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we
decided that the Plan does not have to provide coverage for a Group 3 Power Wheelchair and accessories for
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz Injections (J7321).
You asked the Plan to pre-approve Supartz. You say that Supartz is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Supartz. Our reviewer says that Supartz is not medically necessary. Our physician reviewer found the record does not a show a trial of the plan preferred drugs or any reason why they would be unsafe or ineffective for this 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 Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz Injections (J7321).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT code 64555).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says Medicare only covers implanted peripheral nerve stimulation (PNS).
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found this is considered experimental/ investigational at this point in time. Therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT code 64555).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Procrit. Our reviewer says that the criteria for coverage of Procrit have not been met. Our physician reviewer found the Plan requires a trial of Retacrit before they will approve the requested drug. Based on the medical records provided, there is no indication that the enrollee has tried and failed the required drug, or that the required drug would likely be less effective or 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Personal protective equipment (PPE) (D1999) provided December 8, 2020.
You asked the Plan to pay for the PPE. You say that the service should be covered in full. The Plan denied your request. The Plan says the PPE is not covered under your 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 the Personal protective equipment (PPE) (D1999) provided December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ameluz gel.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is recently diagnosed with melanoma. She also has seborrheic keratosis throughout her body and actinic keratosis on her face. Ameluz (aminolevulinic acid) is covered by the Health Plan, as stated in the policy, only for use with the BF-RhodoLED Lamp. The provider intends to use this agent with blue light photodynamic therapy, not red light. The documentation does not support that the Ameluz gel is medically reasonable and necessary for the enrollee. The documentation does not support that the Ameluz gel is safe and effective 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Ameluz gel.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. 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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of age-related osteoporosis, in which the diagnosis was confirmed by bone density testing. The documentation does not support that Prolia is medically necessary for the enrollee. Although there is documentation of osteoporosis on bone density testing, the available records do not document that the enrollee is receiving 1,000 mg of calcium and at least 400 international units of vitamin D daily as is required for its effective use. Therefore, the enrollee does not meet criteria for the requested drug. 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 Prolia.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the cost-sharing for prescription drugs and a Computed Tomography (CT) scan provided from September 21, 2020, to October 29, 2020.
You asked the Plan to waive the cost-sharing for CT scan. You say that you met your maximum out-of-pocket amount and should not have this additional obligation. The Plan denied your request. The Plan says that the copayment amount you are being charged is correct. The Plan also says that they have reprocessed these claims to waive the copayment for the office visit on October 7, 2020 and reduce the copayment for the CT scan on October 29, 2020 from $200 to $20.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Part B drugs and $200 copayment for CT scans, up to a maximum out-of-pocket amount of $4,500 for 2020.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a summary of the amounts that were applied to your 2020 maximum out-of-pocket amount. We requested this information, but it was not provided to us. You say that had already met your maximum out-of-pocket amount and should not be charged these additional amounts. Without a summary of the amounts applied to your 2020 maximum out-of-pocket amount, we cannot determine whether you had met the $4,500 maximum out-of-pocket amount at the time these claims were processed. Therefore, the Plan has not shown that its decision to ask to you pay these cost-sharing amounts is correct or justified according to the Plan contract. Therefore, we decided that the Plan has to waive the cost-sharing for prescription drugs and a Computed Tomography (CT) scan provided from September 21, 2020, to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services
You asked the Plan to pre-approve the acupuncture services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, only acupuncture care for chronic lower back pain is covered. This request is for treatment of knee pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture 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 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 documentation does not support that an additional 25 days of hospitalization are reasonably expected for you. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nursing facility visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve nursing facility visits. You say that the enrollee completed conservative management and will continue to do so until this authorization is approved. The Plan denied your request. The Plan says 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 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 nursing facility visits to be provided by an out-of-network provider.
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 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 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point (intermittent wound care), as a practical matter, can be provided at a lower 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and the transfer device (E0705).
You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee requires all of the requested accessories for the power mobility device. The Plan denied your request. The Plan says the enrollee does require some of the requested accessories, but not the E2300 or E0705 because they are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Transfer device (E0705) is not a Medicare-covered item as it is not primarily used for medical purposes. 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 pre-approve the power seat elevation feature (E2300) and the transfer device (E0705).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess capsules.
You asked the Plan to pre-approve self-administered drug. You say that other medications have proven to be ineffective, non-sustaining, or non-therapeutic. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and may be covered by the enrollee's Medicare Part D prescription drug benefits instead.
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 Linzess capsules.
Benefits for self-administered drug 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: Favorable

We decided that the Plan has to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that a calcium level test has been ordered, however; there is no medical justification for delaying Prolia until this is obtained. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the enrollee needs to have updated lab testing before he can get Prolia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the enrollee meets the criteria for use of Prolia. Our physician reviewer found denosumab (Prolia) is indicated for treatment to increase bone mass in men with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture or multiple risk factors for fracture; or patients who have failed or and intolerant to other available osteoporosis therapy. In this case, the requested drug is being used for a Food & Drug Administration (FDA) labelled indication. The documentation provided indicates that the drug is safe, effective, and medically reasonable and 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve use of Prolia.