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

We decided that the Plan has to pre-approverotational arc radiation therapy.You asked the Plan to pre-approvethe requested services. The Plan denied your request. 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.MAXIMUS has made multiple attempts to obtain additional information, with no success. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pre-approverotational arc radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided December 4, 2019. You asked the Plan to pay for the dental services. You say that your dental office told you that the service would be covered. The Plan denied your request. The Plan says this request exceeds the frequency limitations. 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. This service is covered 2 times per year. Records show that this service was provided January 14, 2019 and July 15, 2019. 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 limited oral evaluation (D0140) provided December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond April 30, 2020.You asked the Plan to pre-approve the ongoing inpatient care. You say that this is medically necessary care.The Plan denied your request. The Plan says this is not an acute psychiatric illness and is not likely to improve from care delivered at the inpatient level.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 the ongoing inpatient care. Our reviewer says that the continued inpatient psychiatric care is not shown to be reasonable and necessary. Our physician reviewer found this 32-year-old male was involuntarily admitted to the acute inpatient psychiatric hospitalization on March 2, 2020 with Schizoaffective Disorder Bipolar Type, Unspecified, Rule Out Schizophrenia, Alcohol Use Disorder and Cannabis Use Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others without aggressive behaviors. The patient was showing religious preoccupation and spends much time reading the Bible. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of carerather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. 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 ongoing inpatient care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond April 30, 2020
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided on December 28, 2019.You asked the Plan to waive the copayment for the observation stay. You say that nothing was done to help you. You say that the copayment should be removed.The Plan denied your request. The Plan says the copayment 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 $250 copayment for observation services.You have been asked to pay a $250 copayment for the observation stay. The observation stay falls within the "Outpatient hospital 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 copayment for the observation stay provided on December 28, 2019.
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 requires daily physician management, rehab therapy, and oxygen weaning. The Plan denied your request. The Plan says the enrollee does not need complex hospital care with daily physician management.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia with respiratory failure. The enrollee was transiently intubated/ventilated, but has since been extubated and is no longer on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on December 10, 2019 to December 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-directed.
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 has network providers available who can provide 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 psychotherapy provided on December 10, 2019 to December 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 7, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0120) prophylaxis (D1110) provided September 12, 2019.You asked the Plan to pay for the dental services. You say that you went to your same provider that the plan previously paid for when you were told it was time for your cleaning. But you was never told by the provider that they were no longer in the network.The Plan denied your request. The Plan says dental services must be rendered by an in-network dental provider.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 health plan contract says you must use a dentist in the dental network.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when services are rendered by an out of network provider.Therefore, we decided that the Plan does not have to pay for oral exam (D0120) prophylaxis (D1110) provided September 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection, a positioning back cushion and a combination skin protection and positioning seat cushion.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that these items 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 requested items/services are not considered medically reasonable and necessary in this case. None of the above are needed for optimal power mobility device functioning. There is no documented inability to self-pressure relief, or any postural asymmetry. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these items. 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 an expandable controller, expandable controller harness, electronic connection, a positioning back cushion and a combination skin protection and positioning seat cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection. You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is 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 the injection. Our reviewer says that the requested epidural steroid injection is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has neck and shoulder pain, as well as headaches. The enrollee does not have radicular pain or any other evidence-based indication for an epidural 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol tablets.You asked the Plan to pre-approve Tramadol. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.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 Tramadol tablets.Benefits for Tramadol 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 haveto pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that the condition you are suffering from is a medical issue that initially started post-surgery in June 2018 and from then on is an extra financial burden for you to purchase this product.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (denosumab) injections.
You asked the Plan to pre-approve the Xgeva injections. You say that Xgeva is preferable to Zometa since the enrollee has low calcium and is on daily aspirin. The Plan denied your request. The Plan says there is no clinical information showing why Zometa cannot be used with aspirin and low calcium should be corrected prior to use of either of these drugs.
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 the Xgeva injections. Our reviewer says that the requested treatment is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found this review relates to a request for Xgeva to treat a male with prostate cancer involving bones and with low calcium and on daily aspirin. Only limited medical information was submitted for review. There is no documentation that the enrollee has been treated with Zometa. Both drugs are indicated for prophylaxis of bone metastases associated with solid tumors and for osteopenia in men at high risk of fracture receiving androgen deprivation therapy for non-metastatic prostate cancer and for osteoporosis in men per Drugdex. The documentation does not indicate that the use of Zometa would be less effective or have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Xgeva injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva (denosumab) injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Coflex).
You asked the Plan to pre-approve Coflex procedure. You say that the best outcome for this enrollee would be obtained with this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is not enough medical evidence to show that this procedure is safe and effective.
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 Coflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental for use, and more research is needed to show the safety and efficacy of this procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Coflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Coflex).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (CPT 88307) provided to the enrollee on October 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment is not allowed for these Clinical Laboratory Improvement Amendment (CLIA) Lab chargers because they were submitted without a corresponding CLIA number.
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 88307 is "Surgical pathology, gross and microscopic examination." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the claim was submitted to the health plan without a corresponding CLIA number (Clinical Laboratory Improvement Amendments) which is required by Medicare. Also, 88307 26 76 x2 were submitted with modifier 76, which is an inappropriate modifier to be submitted with CPT code 88037 per the modifier crosswalk. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (CPT 88307) provided to the enrollee on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (CPT E0466). You asked the Plan to pre-approve the home ventilator. You say that the clinical information provided supports the need for the device being requested. The Plan denied your request. The Plan says medical necessity was not established by the clinical records provided. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the coverage criteria for a home ventilator have not been met. Our physician reviewer found the enrollee has a diagnosis of COPD with chronic hypoxic respiratory failure. He has had several recent hospitalizations for exacerbations, with pCO2 elevated to 63 and normal pH, which suggests chronic CO2 retention. However, there has been no data from ABG done in a stable state to confirm this. Medicare does not cover a home ventilator when being used as BiPAP. Certain BiPAP devices are capable of providing the AVAPS-AE mode of ventilation, so the enrollee's needs could be met with BiPAP, which he apparently already has. There is no evidence of BiPAP failure (demonstrated hypoxemia at night on BiPAP and usual oxygen, when stable). A home ventilator is not 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 the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (CPT E0466).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve pain management services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON pain management services. You say that there are long wait times for in-network doctors. The Plan denied your request. The Plan says that the requested services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 OON pain management services. Our reviewer says that it is medically necessary for you to receive these services out-of-network. Our physician reviewer found since you are in enough excruciating pain to express suicidal ideation and the injection is not available in network at this time, then it is reasonable and prudent to go to an out of network physician who can provide the care on an urgent basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OON pain management services have been met. Therefore, we decided that the Plan has to pre-approve pain management services to be provided by an out of network (OON) provider.