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

We decided that the Plan does not have to pre-approve Fosnetupitant to be used with Palonosteron.You asked the Plan to pre-approve Fosnetupitant to be used with Palonosteron. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drugs 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 ifthe Plan was correct in denying the request to pre-approve Fosnetupitant to be used with Palonosteron. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of upper lobe, right bronchus or lung. The MAXIMUS Physician Reviewer has determined that the requested regimen of Carboplatin, Pembrolizumab, and Pemetrexed is not FDA-approved for the enrollee's diagnosis without ALK, EGFR, and PD-L1 status. Since the requested chemotherapy drugs were found to be not medically necessary, the use of Fosnetupitant with Palonosteron is not medically reasonable and necessary for the enrollee 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 Fosnetupitant to be used with Palonosteron have not been met.Therefore, we decided that the Plan does not have to pre-approve Fosnetupitant to be used with Palonosteron.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full size sleep safe 2 Hi/Lo bed, custom fitted bed
padding and 30" IV pole Kit.
You asked the Plan to pre-approve full size sleep safe 2 Hi/Lo bed, custom fitted bed padding and 30" IV pole
Kit. You say that current standard twin size bed is in disrepair and the IV kit is needed for feedings in the
evening. The Plan denied your request. The Plan says this is not medically necessary. The enrollee's needs can
be safely met with a hospital bed with approved padding and an IV pole.
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 full size sleep safe 2 Hi/Lo bed, custom
fitted bed padding and 30" IV pole Kit. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the documentation does not
support the need for a Full Size Sleep Safe bed 2, padding, and IV pole. Although the enrollee requires
positioning of the body in ways not feasible in an ordinary bed the documentation does not support that he
requires the full size Sleep Safe Bed 2 and custom fitted bed padding and IV pole. The enrollee's body habitus
does not require a full size bed over a standard size hospital bed. There is no medical reason that an electric
remote is needed to operate the head/foot board of the bed or the IV pole on the bed is medically necessary as
these are convenience 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 full size sleep safe 2 Hi/Lo bed, custom fitted bed padding and 30" IV pole Kit
have not been met. Therefore, we decided that the Plan does not have to pre-approve full size sleep safe 2
Hi/Lo bed, custom fitted bed padding and 30" IV pole Kit.
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 the requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to anIRF.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 enrollee does not meet criteria for admission to an IRF. Our physician reviewer found the enrollee was admitted to acute care on 5/28/20 for decubitus ulcer III with history of staph aureus pneumonia with need for intervention and wound care. Hospital records indicate the enrollee has been on a ventilator for 13-days before weaning off, and has received wound care for pressure ulcers. The enrollee has a colostomy, and has pain management needs. The recent records indicate the enrollee is medically stable, but mostly maximum assist and non-ambulatory. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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.Therefore, we decided that the Plandoes not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a dermatology office visit provided on January 17, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you are appealing this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $20 copayment for a specialist office visit. You have been asked to pay $20 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a dermatology office visit provided on January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308)
rendered by the out of network (OON) provider on December 9, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON)
provider on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on October 21, 2019.
You asked the Plan to pay for the compression stockings. You say that the claim should be paid. The Plan denied your request. The Plan says the compression stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on October 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services
rendered on January 9, 2020 to January 11, 2020.
You asked the Plan to waive the copayment for these services. You say that you were admitted to the hospital
and were not an outpatient. 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 $90
copayment for each emergency room visit.
Review of the file shows that you received ER services from January 9, 2020 to January 11, 2020. The file
shows that you were not admitted as inpatient to the hospital. You have been asked to pay a $90 copayment for
these services. These services fall within the emergency room visit 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 emergency room (ER) services rendered on January 9, 2020 to January 11,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy criteria have not been met.
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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary in this case. The documentation does not support that the enrollee has tried and failed Retacrit or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that your condition does not meet step therapy criteria for Aranesp.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvea hip injection from an out-of-network provider. You say that you want to treat the enrollee.The Plan denied your request. The Plan says there are contracted providers that can provide the services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Omnipod pack.You asked the Plan to pre-approvethe requested items. You say that the enrollee requires multiple basal rates throughout the day.The Plan denied your request. The Plan says the Omnipod does not meet Medicare rules for durable medical equipment.The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-covered because they do not meet the definition of durable medical equipment.  We looked at the file and Medicare rules. 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 pre-approvean Omnipod pack.Benefits for the requested itemsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that inpatient rehab is the best chance at the enrollee being able to return to the home setting.The Plan denied your request. The Plan says the enrollee does not need an intensive team for 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 physician reviewer found that the enrollee had a fractured right hip. She underwent intramedullary nailing. The enrollee was at maximum assist for ambulation. The enrollee is medically stable. She does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. It is not clear that the enrollee would reasonably be expected to 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intramuscular diagnostic injections provided from January 9, 2020 to February 6, 2020.You asked the Plan to waive the copayments for intramuscular diagnostic injections. You say that you were told that you would only owe 20% coinsurance.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received intramuscular diagnostic injections from January 9, 2020 to February 6, 2020 for a total of 5 services at an outpatient hospital facility.Therefore, you are responsible to pay the allowed amount of $61.71, which is less than the $250 copayment, per each service. The total amount you owe is: $61.71 (allowed amount) x 5 (services) = $308.55. You have been asked to pay the total copayment amount of $308.55 for intramuscular diagnostic injections. Intramuscular diagnostic injections fallwithin the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forintramuscular diagnostic injections provided from January 9, 2020 to February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy (G6002, 77336, 77525) provided from
January 9, 2020 to January 17, 2020.
You asked the Plan to pay for radiation therapy. You say that the Plan should cover this service. The Plan
denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that MAOs pay the enrollee the difference between
original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA plan's innetwork
cost-sharing for the same category of items and services.
We looked at the file and Medicare rules. The information you submitted shows that original Medicare paid for
the services at issue with a 20% enrollee coinsurance. The Plan's cost sharing for these services is also a 20%
coinsurance. The Plan therefore has no responsibility on these services. Therefore, we decided that the Plan
does not have to pay for radiation therapy (G6002, 77336, 77525) provided from January 9, 2020 to January
17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 20, 2020.You asked the Plan to pay for the domiciliary or rest home visit.The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 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 a domiciliary or rest home visit provided on February 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99344) provided on December 5, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for an OON home visit. You say that this was an urgent service. The Plan denied
your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 the home visit (99344) provided on December 5,
2019 by an out of network (OON) provider.