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

We decided that the Plan does not have to pre-approve treatment with Zilretta (J3304).
You asked the Plan to pre-approve Zilretta. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment 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 Zilretta. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that criteria for Zilretta injection not met. There is no documentation of a prior steroid injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Zilretta (J3304).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a standard manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation that clearly indicate what mobility-related activities of daily living in the home cannot be overcome using an optimally fitted cane or walker.
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 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 substantiate their denial. The case file makes it clear that the
plan had some medical records to make their decision in this case. However, these records were not provided for MAXIMUS to review. Therefore, we decided that the Plan has to pre-approve a standard manual wheelchair.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
You asked the Plan to pre-approve the SSBCI benefit. You say that you should have been approved for this benefit. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefit for the Chronically Ill for 2021.
Medicare generally does not cover supplemental benefits. However, the Plan offers a special supplemental benefit for the chronically ill (SSBCI) that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, the record does not show that you have been diagnosed with any of the qualifying diagnoses. Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable liquid oxygen system (E0434) to be provided
by an out-of-network (OON) provider.

You asked the Plan to pre-approve a portable liquid oxygen system. You say that you need this while you are
traveling. The Plan denied your request. The Plan says this is 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
a portable liquid oxygen system (E0434) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5283).
You asked the Plan to pre-approve the removable unilateral partial denture. You say that you need this denture because you got bariatric surgery and need to swallow food in the smallest pieces as possible. You also say that with your teeth right now you cannot do this. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 a removable unilateral partial denture (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adolescent dentition (D8080).

You asked the Plan to pre-approve the comprehensive orthodontic treatment. You say that you would like this service to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 a comprehensive orthodontic treatment of the adolescent dentition (D8080).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neupro patches.
You asked the Plan to pre-approve Neupro. You say that Neupro is a necessary therapy for the enrollee's
medical condition. The Plan denied your request. The Plan says the drug is not covered under the Part B
benefit.
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 Neupro patches.
Benefits for Neupro 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.

You asked the Plan to pre-approve the shower. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99204) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that your PCP recommended this provider because you have a urinary condition The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the outpatient office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740).
You asked the Plan to pre-approve a porcelain/ceramic crown. You say that you do not have many teeth and the crown is necessary to keep your bridge. The Plan denied your request. The Plan says this service is not covered under your dental benefits.
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 a crown - porcelain/ceramic (D2740).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on January 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you can choose to receive care from out-of-network providers. The plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The provider in this case is not a network provider with the Plan. However, the Plan contract states that enrollees can choose to receive care from out-of-network providers. The Plan will cover these services as long as they are covered benefits that are medically necessary. Additionally, the Plan contract states that the enrollee does not need to get a referral or prior authorization when receiving care from an out-of-network provider. Therefore, we decided that the Plan has to pay for the psychotherapy (90832) rendered by the out-of-network (OON) provider on January 22, 2021.
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: 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 enrollee's needs for medically necessary acute care services demonstrate appropriate LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.
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 receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires which are not available at the health care setting being offered by the Plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that you need dentures because you do not have any teeth. The Plan denied your request. The Plan says this service is not covered under your 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 a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve provisional retainer crowns - further treatment or completion of diagnosis necessary prior to final impression (D6793), provisional pontics - further treatment or completion of diagnosis necessary prior to final impression (D6253), interim abutment (D6051), pontics - porcelain fused to noble metal (D6242), abutment supported retainers for porcelain fused to metal fixed partial denture (noble metal) (D6071), and custom fabricated abutmenst - includes placement (D6057).
You asked the Plan to pre-approve provisional retainer crowns, provisional pontics, interim abutments, pontics, abutment supported retainers and custom fabricated abutments. You say that the services are medically necessary for chronic facial pain. The Plan denied your request. The Plan says these services are not covered under your dental benefits.
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 provisional retainer crowns - further treatment or completion of diagnosis necessary prior to final impression (D6793), provisional pontics - further treatment or completion of diagnosis necessary prior to final impression (D6253), interim abutment (D6051), pontics - porcelain fused to noble metal (D6242), abutment supported retainers for porcelain fused to metal fixed partial denture (noble metal) (D6071), and custom fabricated abutmenst - includes placement (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic - cast high noble metal (D6210) and the retainer crown (D6790).

You asked the Plan to pre-approve the pontic and retainer crown. You say that the Plan already approved a bridge for your bottom jaw, so they should also approve a bridge on the top jaw. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 the pontic - cast high noble metal (D6210) and the retainer crown (D6790).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repair, nonunion or malunion, of the femur, distal to head and neck; without graft (27470) to be rendered by the out-of-network (OON) provider at the in-network benefit level.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested service can be provided at a participating facility. The enrollee may utilize their out-of-network benefits to receive the service at an out-of-network facility.
The contract with the Plan says that enrollees may obtain care from in-network and out-of-network providers. Enrollees may receive care from an out-of-network provider for most covered services using the POS benefit option. If an enrollee needs medical care that Medicare requires the plan to cover and the providers in the network cannot provide this care, the enrollee can get this care from an out-of-network provider. Authorization should be obtained from the plan prior to seeking care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a repair, nonunion or malunion, of the femur, distal to head and neck; without graft (27470) to be rendered by the out-of-network (OON) provider at the in-network benefit level
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric treatment. Our reviewer says that the services are not medically necessary.
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 28, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to safety as you awaited placement. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric treatment
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided October 21, 2020, through November 3, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that hospital staff did not give you accurate information about your copayment for the inpatient stay. The Plan denied your request. The Plan says the copayment was 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 $290 copayment for each Medicare-covered day for days 1-6 for each inpatient hospitalization. You have been asked to pay a total of $1,740 ($290 copayment per day x 6 days) for the inpatient rehabilitation
stay. This service 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 the inpatient rehabilitation stay provided October 21, 2020, through November 3, 2020.
Your complaint about potentially receiving misinformation from hospital staff at the contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the additional mileage. The Plan denied your request. The Plan says he distance between the member's address and the requested provider location is 30 miles over the 50-mile limit. This exceeds the allowed mileage stated in the subscriber agreement.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.