Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you have seen this doctor for 20 years. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 physician services provided on March 4, 2021 by an out of network (OON) provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service is 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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. Specifically, the LTACH does not offer any medically necessary services for this enrollee that they are not already receiving. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
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 records do not support the ability for the enrollee to tolerate an intensive rehab therapy program.
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 shortness of breath, tremors and trouble walking. His medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation 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: 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 your goal is to return home with increased mobility.
The Plan denied your request. The Plan says you do not require an intensive therapy program with multiple
visits by a rehab doctor per week.
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 you were admitted to the acute care hospital for respiratory failure, pneumonia, urinary tract infection and
acute kidney injury. Your medical conditions are stable. The complexity of your nursing, medical and
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medtronic MiniMed670G non-therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve non-therapeutic CGM. You say that this component is required for your insulin pump system to operate. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a non-therapeutic CGM is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare only covers therapeutic continuous glucose monitors are defined in the previous section. 

We looked at the file and Medicare rules. The Medtronic MiniMed670G is not intended to replace a blood glucose monitor for making diabetes treatment decisions, and therefore is not considered to be a therapeutic CGM. Based on this information, we decided that Medicare rules for coverage of non-therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Medtronic MiniMed670G non-therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for an office visit for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance.

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 referral to an out-of-network provider for an office visit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided February 10, 2021.
You asked the Plan to provide additional payment for the limited oral exam and periapical x-ray. You say that you do not agree with the cost-sharing. The Plan denied your request. The Plan says the limited oral exam is not covered under your benefits and the periapical x-ray was processed correctly based on OON 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. The Plan covers the limited oral exam and periapical x-ray when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. The record shows that the Plan covered 50% of the allowed amount for the periapical x-rays. Since the service was provided OON, you are responsible for 50% coinsurance of the allowed amount plus the difference between the allowed amount and the total cost billed by the provider. Additionally, though the Plan offers dental benefits in excess of Medicare coverage, the limited oral exam is not among those services covered by the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) provided February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal decompression therapy with a chiropractor.
You asked the Plan to pre-approve the therapy. You say that this would be more beneficial than surgery. The
Plan denied your request. The Plan says these services are not covered based on Medicare rules.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve spinal decompression therapy with a chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical extractions (D7210), implant placements (D6010), alveoloplasty (D7310), bone graft replacements (D7953), anesthesia (D9222, D9223) and unspecified adjunctive procedures (D9999) provided from August 10, 2020, to November 11, 2020.

You asked the Plan to pay for the dental services.. You say that you thought some of these surgical services would be covered. The Plan denied your request. The Plan says there is no indication that these services were completed in relation to a tumor or radiation treatment. Therefore, these services are dental in nature and are not covered by your Plan.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for surgical extractions (D7210), implant placements (D6010), alveoloplasty (D7310), bone graft replacements (D7953), anesthesia (D9222, D9223) and unspecified adjunctive procedures (D9999) provided from August 10, 2020, to November 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right-side sacroiliac joint injection.

You asked the Plan to pre-approve the requested injections. The Plan denied your request. The Plan says there is no documentation of right-side sacroiliac joint dysfunction.

The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under certain medical 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 requested injections. Our physician reviewer found that the enrollee has chronic low back pain with left-sided buttock pain and radiation to the left thigh. The request was for bilateral sacroiliac joint injections. There is no indication that there is right sided SI joint involvement. Therefore, the request for a right SI joint injection 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 requested injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a right-side sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.

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. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had spine surgery after a workplace injury and has residual pain. The peer-reviewed literature reports low efficacy of RFA of the lateral sacral branches. The services are therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on December 18, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency services rendered by an in-network provider. The enrollee has been asked to pay a $90 copayment for the emergency room visit provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided
on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation (A0427) received February 9 and March 13, 2021.

You asked the Plan to waive the copayments for the ambulance transportation. You say that you would like the Plan to waive the copayments. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 Ambulance Services. 

You have been asked to pay $580 in copayments ($290 per date of services) for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 copayments for the ambulance transportation (A0427) received February 9 and March 13, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to approve continued skilled nursing facility (SNF) services after July 13, 2021.
You asked the Plan to approve SNF care. 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. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 13, 2021. The NOMNC in the submitted documentation is blank. MAXIMUS requested a signed, valid NOMNC from the Plan but a blank, unsigned copy was sent in response. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to approve continued skilled nursing facility (SNF) services after July 13, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a personal mobility deficit but it is not clear that it impairs participating in mobility-related activities of daily living (MRADLs) in the home or that it cannot be helped by a walker, cane, or manual wheelchair. The documentation does not show that you can safely operate a power mobility device in the home and that the home provides adequate space. The power scooter is therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional trips for routine transportation.

You asked the Plan to pre-approve the additional trips. You say that you used your last 2 trips due to misinformation given by the office manager. You say that you should be reimbursed those 2 trips so that you can use them for your rescheduled visit. 

The Plan denied your request. The Plan says the transportation benefit only allows for 60 trips. The Plan says that the frequency limit has been exhausted. The Plan also says that additional trips cannot be approved.

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. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 24 additional trips for routine transportation.

Your complaint about being misinformed by the office manager 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on October 27, 2020.

You asked the Plan to pay for the physical therapy services. You say that The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 did not pre-approve the physical therapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on
October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis (L0650) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the lumbar-sacral orthosis. You say that this request is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to meet your medical needs.

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 lumbar-sacral orthosis (L0650) to be provided by an out of network (OON) provider.