Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services (G0299).
You asked the Plan to pre-approve the home health services. You say that the home health services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records did not clearly show that skilled nursing services at the home are required to effectively treat the patient's condition. No direct medical care was required besides the monthly catheter changes which were being performed at the Urology office and not at home. 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay and an emergency room visit provided by participating providers fromAugust 4, 2020, to August 16, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay and an emergency room visit. You say that you would like help with this bill. The Plan denied your request. The Plan says the correct copayments have 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 $395 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/in-network and a $90 copayment emergency care/in-network. You have been asked to pay a $395 copayment per day for days 1-2 for an inpatient hospital and a $90 copayment for an emergency room visit The total amount you are being asked to pay is $880 ($790 ($395 x 2 days = $790) + $90 = $880). An inpatient hospital stay falls within the inpatient hospital care/in-network and an emergency room visit falls within the emergency care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay and an emergency room visit provided by participating providers fromAugust 4, 2020, to August 16, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveINJECTAFER.You asked the Plan to pre-approvethese 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 INJECTAFER is covered when specific criteria are met.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 has anemia on chronic kidney disease but does not meet the criteria for intravenous (IV) iron. Her hemoglobin is less than 12, at 9.9, but her ferritin is not less than 300, in fact it is high at 891. Furthermore, there has been no documentation that the patient has had an inadequate response to a consistent trial of oral iron or a documented intolerance or contraindication to oral iron therapy. The requested iron injection is FDA approved for iron deficiency anemia with unsatisfactory response to oral iron, in the non-dialysis dependent patient. The services are 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-approveINJECTAFER.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief Cooled Radiofrequency Ablation (64454, 64624).
You asked the Plan to pre-approve the ablation procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.
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 the ablation procedure. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found this treatment is not standard for osteoarthritis and is currently categorized as investigational. There is insufficient high quality data to support this treatment modality 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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief Cooled Radiofrequency Ablation (64454, 64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper partial denture (D5221) provided on October 5, 2020.
You asked the Plan to pay for the dental item. You say that a plan representative advised you had a $0 copayment and $1,000 per year. You say that you dropped your dental rider. You say that the last time you called, you were told that a rider was not needed. You say that you feel that you were misinformed by the plan representative. The Plan denied your request. The Plan says the immediate upper partial denture is not listed as a covered service. The Plan also says that any services not listed are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate upper partial denture (D5221) provided on October 5, 2020.
Your complaint about being misinformed by the plan representatives 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional benefits for hearing aids.
You asked the Plan to pre-approve the additional benefits. You say that you need your hearing aids replaced and fixed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only once every three years, with a maximum benefit of $3,000 per ear. Hearing aids were last received less than three years ago on January 15, 2019. The maximum benefit was paid on this date. You would not be eligible for hearing aids again until January 15, 2022. Based on this information, we decided that the Plan's rules for coverage of the additional benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional benefits for hearing aids.
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.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 there are no complex nursing or rehabilitation needs and the patient does not require
treatment by multiple therapies. 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.
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. Specifically, the enrollee does not meet criteria for
IRF care. This means the service is not reasonable or necessary. Therefore, we decided that the Plan does not
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee arthroscopy.You asked the Plan to pre-approvethese 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 notcovered. 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 has right knee pain. Exam reveals mild intra-articular effusion with tenderness along the medial compartment/most tender posteromedial. There is a positive bounce test as well as McMurray's. MRI demonstrated a complex tear of the posterior horn of the medial meniscus. There is no documentation of at least three months of trial and failure of conservative measures. The requested knee arthroscopy is not supported by peer reviewed literature in the presence of the degenerative changes noted on x-rays. The surgery is 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-approvea knee arthroscopy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysa review of the current medical iterature indicates that this service is considered experimental and investigational.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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forcritical care services (99291) provided on July 11, 2020.You asked the Plan to pay forthe critical care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the record. Specifically, the record does not document the amount of time spending the critical care services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forcritical care services (99291) provided on July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 11 to 12 of the Plan's 2020 EOC.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 10, 2020 and billed under code 87507 described as Infectious agent detection by nucleic acid (DNA or RNA).
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. Maximus overturned the Plans denial. The Plan requested a reopen and stated that the reviewer incorrectly identifies the submitted code. Infectious agent detection, gastrointestinal pathogen, code 87507, is covered by Medicare in beneficiaries with immunodeficiency. The Plan states there is no documentation of immunodeficiency in the medical record. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that for payment of code 87507, any diagnosis submitted must have documentation in the patient's record to support coverage and medical necessity. The submitted medical record must support the use of the selected ICD-10-CM code(s). In this case, the medial records provided show no indication of immunodeficiency in the enrollee. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on July 10, 2020 and billed under code 87507 described as Infectious agent detection by nucleic acid (DNA or RNA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you have severe lung issues and need constant breathing treatments and rehab for your hip to have your heart condition monitored.The Plan denied your request. The Plan says that you can safely receive the services you need 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 above.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 basedon Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation thatyou will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's ongoing skilledtherapy and nursing needs can be provided at a lower level of care such as at a Skilled Nursing Facility.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitationcare. The patient was admitted for diabetic ketoacidosis, sepsis and encephalopathy. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital care from January 21, 2020, through January 25, 2020.
You asked the Plan to pre-approve inpatient hospital care. You say that you were provided misleading information from the Plan representative regarding the need for authorization. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 verify if their Plan representative provided incorrect information regarding the authorization process. Therefore, we decided that the Plan has to pre-approve inpatient hospital care from January 21, 2020, through January 25, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Creon DR 36,000 units cap.
You asked the Plan to pre-approve Creon DR. You say that this service is medically necessary. The Plan
denied your request. The Plan says Part B programs can only provide limited benefits for prescription drugs.
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 Creon DR 36,000 units cap.
Benefits for Creon DR may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.