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

We decided that the Plan does not have to provide coverage for additional routine transportation under the Medicare benefit.

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 48 one-way routine transportation trips are covered under the Medicare benefit. The Plan suggests you check this benefit under your Medicaid benefit if applicable.

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 48 trips per year under the Medicare benefit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation under the Medicare benefit.

Maximus does not have jurisdiction over your Medicaid benefits. The Plan suggests you contact Medicaid for further information regarding additional transportation assistance.
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 benefits can be obtained at a lower level of care.

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 the enrollee's care needs can be met at a lower level of 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. Specifically, the enrollee's needs can be obtained at
a lower level of care. This means admission to an IRF is not medically necessary or reasonable. 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 inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says IRF care is not medically reasonable and 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 the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the patient does require physical therapy and occupational therapy services, based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Finally, based on the medical records provided there is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.

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 pay for an orthosis (L2397, L1833) provided to the enrollee.

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 there was no claim for the ordering physician.

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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the medical records show knee osteoarthritis. There is no instability of severe deformity documented.
Knee bracing is not medically needed in this case.

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 an orthosis (L2397, L1833) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.

You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says you have been given the names of providers in network who can provide treatment.

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 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. We found no exception that would require the Plan to pre-approve these services out of network. Therefore, we decided that the Plan does not have to pre-approve out of network physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical or vaginal cancer screening (G0101).

You asked the Plan to pay for a cervical or vaginal cancer screening. You say that this should be covered. The Plan denied your request. The Plan says this was provided fewer than two years after your previous screening.

The Plan must follow Medicare rules. Medicare rules say that a screening pap smear and related services provided to a woman for the early detection of cervical cancer and pelvic examination are covered if she has not had such a test during the preceding two year or is at high risk of developing cervical cancer.

We looked at the file and Medicare rules. The record shows that you had last had a cervical cancer screening, less than two years prior to the service at issue. The record does not show that you are at high risk of developing cervical cancer. Based on this information, we decided that Medicare rules for coverage of a cervical or vaginal cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for a cervical or vaginal cancer screening (G0101).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation care.

You asked the Plan to waive the copayment for the observation services. You say that you called the plan with no resolution. The Plan denied your request. The Plan says observation services are billed as outpatient services, therefore the correct copayment was 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 $20 copayment for outpatient hospital services.

You have been asked to pay a $40 in total copayments (a $20 copayment for each of 2 dates of service) for the observation services. The observation services fall 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 care.
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 routine
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 24 one-way routine transportation trips. Once this benefit is exhausted, it
cannot be extended. Medicare does not make exceptions for supplemental benefits. Therefore, we decided that
the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ukoniq Tablets for the enrollee.

You asked the Plan to pre-approve Ukoniq Tablets. You say that this drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B.

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 Ukoniq Tablets for the enrollee.

Benefits for Ukoniq 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) infusion rendered on July 8, 2020.

You asked the Plan to pay for these services. You say that you were not told about the copayment in advance. The Plan denied your request. The Plan says the copayment was 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital facility.

Review of the file shows that you received IV infusion services on July 8, 2020. Per the contract with the Plan, there is a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $146.02. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $146.02 for these services.

Therefore, we decided that the Plan does not have to pay for the intravenous (IV) infusion rendered on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee had cardiovascular risk assessment testing. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 4, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a lab requisition is needed to determine the clinical utility of the testing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the services at issue are not supported in the medical record. In this case, the records do not include an order from the treating physician to show the services were ordered for a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 physician's 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 physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ophthalmologist service provided on October 29, 2020.

You asked the Plan to adjust the copayment for the ophthalmologist service. You say that this was a routine eye exam. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for a Vision Care outpatient visit for services to diagnose and/or treat a disease or condition of the eye. 

You have been asked to pay a $40 copayment for the ophthalmologist service. The provider is not a Plan preferred provider. The provider submitted the claim as a diagnostic comprehensive eye exam. The ophthalmologist service falls within the Vision Care 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 adjust the copayment for the ophthalmologist service provided on October 29, 2020.
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 services are medically necessary. The Plan denied your request. The Plan says the member can benefit from a lower level of care.

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 the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and the patient does not require an intensive inpatient rehabilitation therapy 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. Specifically, the member can receive services from a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services.

You asked the Plan to waive the copayment for the physical therapy services. You say that the copayment should be waived. The Plan denied your request. The Plan says the National Pandemic waiver is not applicable to physical therapy services.

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 $10 copayment for outpatient rehabilitation services.

You have been asked to pay $50 in copayments ($10 per date of service) for the physical therapy services. The physical therapy services 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 waive the copayment for physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with the inpatient copayment charges. The Plan denied your request. The Plan says the correct cost share amount 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 $295 copayment for inpatient hospital care. You have been asked to pay a total of $590 in copayments (a $295 copayment for each of two days charged by the hospital) for the inpatient hospital stay. This stay falls within the inpatient hospital care 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 inpatient hospital stay.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the clinical criteria for coverage have not been met.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications, had stable vital signs, and was treated for alcohol withdrawal. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a standby assist level with functional mobility, including gait to 200 feet with a rolling walker. The enrollee required varying assist with activities of daily living. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits unless the service is urgent or emergent or when it is not available in-network. The service you request is not considered urgent or emergent.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network physician services.

You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not 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 provide coverage 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 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 provide coverage for these items/services. Therefore, we decided that the Plan does not have to provide coverage for out of network physician services.