Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says a nursing home can be approved.
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 enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does 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 this
enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve filgrastim treatments to be provided with chemotherapy.
You asked the Plan to pre-approve the filgrastim treatments. You say that it is felt this is medically necessary as part of the enrollee's cancer treatment. The Plan denied your request. The Plan says the drugs being used for chemotherapy do not have an incidence of febrile neutropenia of over 10%. As such, this is not considered reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that coverage for filgrastim is allowed when provided within the FDA-approved indications. 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 filgrastim treatments. Our reviewer says that the requested use of filgrastim is not considered reasonable and necessary in this case. Our physician reviewer found the LCD indicates that coverage is allowed for FDA-approved indications. These indications include use for patients receiving myelosuppressive anti-cancer drugs associated with a significant incidence of febrile neutropenia. The enrollee is being treated with Ninlaro (Ixazomib) and Xpovio (Selinexor). Pepaxto at a lowered 30 mg dosing regimen with dexamethasone. Pepaxto is associated with an incidence of febrile neutropenia of 6%. Ninlaro is associated with an infrequent incidence of febrile neutropenia. Xpovio is associated with an incidence of febrile neutropenia of up to 3%. This does not constitute a significant incidence of febrile neutropenia. As such, the criteria for coverage are not met. 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 filgrastim treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve filgrastim treatments to be provided with chemotherapy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (99601) for home infusion therapy (S9329) with Hydromorphone (J1170), Prialt (J2278) and Lioresal (J0475) to be provided by an OON provider.
You asked the Plan to pre-approve skilled nursing visits for home infusion therapy with Hydromorphone, Prialt, and Lioresal. You say that there are limited in-network providers within a reasonable traveling distance to service your intrathecal pump. The Plan denied your request. The Plan says rules for home health services have not been met.
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 skilled nursing visits (99601) for home infusion therapy (S9329) with Hydromorphone (J1170), Prialt (J2278) and Lioresal (J0475) to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, orbit, face, and/or neck; without contrast material(s) (CPT code 70540), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the enrollee continues to have radicular symptoms over a year and many attempts have been made for an MRI approval. The Plan denied your request. The Plan says you requested the wrong code.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file, and Medicare rules. This test was ordered with the wrong billing code. The Plan states the test ordered will not provide the information needed by the enrollee's doctor. The Plan states this test is not medically necessary and the test you need can be covered if a new request is sent with the correct billing code. The Plan states the correct code is 72141 and this is the code for an MRI of the cervical spine. Therefore, we decided that the Plan does not have to pre-approve MRI, orbit, face, and/or neck; without contrast material(s) (CPT code 70540), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 4, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. 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 4, 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 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0670) provided to the enrollee on July 16, 2020.
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery. 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 E0670 is "Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the device. Our reviewer says that the services at issue in this were not supported by the medical records. Our coding reviewer found the documentation submitted does not confirm that the DME was actually delivered. The service cannot be confirmed as performed in this case. We looked at this coder's review, the file, and Medicare rules. The required documentation pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0670) provided to the enrollee on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide vascular surgeon office visits to be provided by an OON provider.
You asked the Plan to provide vascular surgeon services. You say that the enrollee has been seen by you for years. The Plan denied your request. The Plan says they have in-network vascular specialists who can provide the specialist services.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network vascular surgeon services have not been met. Therefore, we decided that the Plan does not have to provide vascular surgeon office visits to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this was denied saying that you do not have diabetes mellitus, but your doctor has confirmed that you do have this condition. The Plan denied your request. The Plan says that you do not meet the criteria for this CGM as you do not use three or more insulin injections per day.
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. No medical records were submitted with the original case file from the Plan. Maximus made two requests for medical records and/or a prescriber statement to support whether criteria for the CGM were met. As of the end of the appeal time frame, these have not been received. As such, we have no direct evidence to support that the enrollee does not meet criteria for the CGM, as argued by the Plan. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you thought you would only owe a specialist copayment. 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 20% coinsurance for Medicare Part B prescription drugs.

You received a Medicare Part B drug. The total allowed amount is $6,090 and 20% of that is $1,218.

You have been asked to pay the total coinsurance amount of $1,218 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription 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 a Medicare Part B drug.
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 enrollee had a hip fracture then developed chest pain and had a heart attack. You state the enrollee is ready to be discharged and needs inpatient rehabilitation. 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a femur fracture after a fall. Post-operative complications included NSTEMI treated medically, and anemia managed with a blood transfusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120).

You asked the Plan to pay for the dental service. You say that you received the services at a dental school. You say that you had no say in who performed the procedure. You say that the rates are about half of what an individual dental provider would charge. You also say that it should not matter if a dentist has opted out of Medicare if services are rendered at an accredited dental school. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.

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 and the periodic oral evaluation is listed as a covered service, dental services performed by a dentist who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ingrezza Initiation Pack (J8499).
You asked the Plan to pre-approve Ingrezza Initiation Pack (J8499). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Ingrezza Initiation Pack (J8499).
Benefits for Ingrezza Initiation Pack (J8499) 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a visual field examination provided by a participating provider.

You asked the Plan to waive the deductible for a diagnostic test. You say that you do not agree with this deductible. The Plan denied your request. The Plan says the correct deductible has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests/diagnostic tests.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for outpatient diagnostic tests/diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time a diagnostic test. The total amount you are being asked to pay is $73.63. Therefore, we decided that the Plan does not have to waive the deductible for a visual field examination provided by a participating provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgery to treat a metastatic sarcoma of the thigh and was treated for pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20 MG Tablet.
You asked the Plan to pre-approve Xarelto 20 MG Tablet. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B Drug benefit.
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 Xarelto 20 MG Tablet.
Benefits for Xarelto 20 MG Tablet. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2020.
Appeal type: Testing
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 outpatient surgery. You say that you should not have to pay for this because they messed it up. 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 $250 copayment for outpatient surgery.

You have been asked to pay $190.03 which is less than your copayment amount of $250 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery 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.