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

We decided that the Plan does not have to waive the copayments for an Emergency Room visit (99285) and a chest x-ray (71046) received October 30, 2019 to November 20, 2019.
You asked the Plan to waive the copayments for the emergency room visit and x-ray. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 $90 copayment for Emergency Care and a $95 copayment for Outpatient X-rays. You have been asked to pay a $90 copayment for an Emergency Room visit and a $95 copayment for the outpatient chest x-ray. 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 an Emergency Room visit (99285) and a chest x-ray (71046) received October 30, 2019 to November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the drug requires then
enrollee meets medically-accepted standards.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We looked at the file, and Medicare rules. In this case, there were insufficient medical records provided to
show the drug would be used for a specific treatment strategy. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have
to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Boniva 150mg tablets.
You asked the Plan to pre-approve the Boniva tablets. You say that this medication is necessary. The Plan
denied your request. The Plan says this oral drug is not covered by Medicare Part B.
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 Boniva 150mg tablets.
Benefits for the Boniva tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on September 27,
2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that
advance care planning services were rendered on the billed date of service. Based on this information, we
decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we
decided that the Plan does not have to pay for advance care planning (99497) provided on September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 has a history of
hypertension, coronary artery disease, and NYSHA Class III congestive heart failure with a reduced left
ventricular ejection fraction. The requested CardioMEMs device is considered experimental/investigational in
nature due to uncertain efficacy. 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-approve a CardioMEMs HF System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits, the
occupational therapy visits, and the speech therapy visits provided from March 2, 2020 to March 16, 2020.
You asked the Plan to reduce the copayments for the physical therapy visits, the occupational therapy visits,
and the speech therapy visits. You say that you were told there would only be one $40 copayment per day for
the services. The Plan denied your request. The Plan says you have been charged the correct cost sharing
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 a $40
copayment for Medicare covered Occupational therapy visits and a $40 copayment for Medicare covered
Physical and/or Speech and Language therapy visits.
You have been asked to pay a total of $600 for the physical therapy visits, the occupational therapy visits, and
the speech therapy. ($40 x 15 visits = $600). The physical therapy visits, the occupational therapy visits, and
the speech therapy fall within the "Outpatient rehabilitation 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 reduce the copayments for the physical therapy visits, occupational therapy visits, and speech
therapy visits provided from March 2, 2020 to March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma (PRP) injections.
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 submitted records show that you have chronic low back pain and swelling in both feet. The requested PRP injections are considered experimental/investigational in nature that does not have an evidence-based indication. There are only anecdotal reports of the use for back pain and they are not part of any clinical practice guidelines. 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-approve platelet-rich plasma (PRP) injections.
Local Coverage Determination (LCD) L33777 referenced by the Plan is retired and was not used in the MAXIMUS determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that a CGM would be easier for you to use.
The Plan denied your request. The Plan says that you do not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above
criteria have been met.
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or
more times a day or testing your blood glucose four or more times a day. Based on this information, we
decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that
the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942) and the pain
assessment (G8730) rendered by the out of network provider on November 27, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide 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 chiropractic manipulative treatment (98942) and the pain assessment (G8730)
rendered by the out of network provider on November 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the need for a continuation of care. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi.
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. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 breast cancer
diagnosed in 2005. Aloxi is indicated for chemotherapy with a high to intermediate antiemetic potential or for
patients with nausea on prior antiemetic regimens. The enrollee is receiving paclitaxel, which has low
emetogenic potential, and there is no documentation of issues with nausea or vomiting. The requested Aloxi 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 Aloxi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing.
You asked the Plan to pre-approve the requested dental services. You say that the enrollee's periodontal health has deteriorated. The Plan denied your request. The Plan says the service is not covered by the enrollee's plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UPWalker lite.
You asked the Plan to pre-approve the requested walker. The Plan denied your request. The Plan says the
provider is not a Medicare-certified provider.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The documentation does not show that the provider of the UPWalker
lite is eligible to provide services under Original Medicare. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to preapprove
an UPWalker lite.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose CT scan (LDCT) of the chest for lung cancer screening.
You asked the Plan to pre-approve the LDCT. You say that you have been diagnosed with lung nodules and need to have annual LDCT scans to monitor them. The Plan denied your request. The Plan says the criteria for LDCT have not been met.
The Plan must follow Medicare rules. Medicare rules say that LDCT screening is covered for enrollees with a 30 or more pack-year smoking history who are asymptomatic. In this case, your documented smoking history is 17.5 pack-years. in addition, you have a history of lung nodules, meaning you are not asymptomatic. As such, the rules for coverage of the LDCT have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-dose CT scan (LDCT) of the chest for lung cancer screening.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional
transportation is necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot
be extended.
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 12 trips per year. At the time of the appeal, 9 of the 12 trips provided
were used. Neither Medicare nor the Plan makes exceptions to supplemental transportation benefits.
Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 18, 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 Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Units) remains not supported.
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 HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records provided showed an order for comprehensive testing, however, there was no medical credentials associated with the signature to confirm a medical professional ordered it to justify the code, G0483. Also, there is no diagnosis code or clinical indication noted. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation for the
enrollee.
You asked the Plan to provide coverage for additional routine transportation for the enrollee. You say that
additional transportation coverage is necessary. The Plan denied your request. The Plan says once this benefit
is exhausted it cannot be extended. 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 12 trips per year. The enrollee has exhausted
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not
have to provide coverage for additional routine transportation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of hypertension, hyperlipidemia, coronary artery disease, atrial fibrillation, COPD, sleep apnea, diabetes, obesity and NYSHA Class III congestive heart failure requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF would be the best place for the best outcome given the enrollee's current state. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition the enrollee does not meet the requirements.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an 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 IRF admission and services.