Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between a power wheelchair
and power seating option.

You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says your left upper limb strength and function are therefore adequate
for you to be able to control the power option using its own switch which is included in the allowance of the
power option.

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. Medicare guidance says that the
electronic connection is not medically necessary. The power option comes with its own switch. Therefore, we
decided that the Plan does not have to pre-approve an electronic connection between a power wheelchair and
power seating option.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to the hospital for falls and bilateral thigh hematomas. The enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan does not have to waive or reduce the copayment charged for skilled nursing facility (SNF) services provided from February 1, 2020 to February 29, 2020.

You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is correct. You stated you were received SNF services from February 7, 2020 to February 29, 2020 and not from February 1, 2020 to February 29, 2020. The Plan denied your request. The Plan says this cost share was charged based on the days of service received and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not calculate the cost share correctly. The Plan says that the claim for services from the provider show you actually received SNF services from January 17, 2020 to March 13, 2020 in total. The Plan provided those claim records. The Plan states the contract is clear that there is a $0 copayment, per day, for days 1 to 20 for skilled nursing facility services, and a $178 copayment, per day, for days 21 to 100. The Plan states the records show that you were not discharged on February 29, 2020 and that you were actually discharged March 13, 2020. Therefor the $4272.00 copayment applied was correct.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $178 per day for days 21 to 100 of a SNF stay. You have been asked to pay the correct amount based on your contract with the Plan and the dates you received SNF services. 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 or reduce the copayment charged for skilled nursing facility (SNF) services provided until the actual discharge date of March 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you need to continue treatment to regain maximal function. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital with COVID-19. The physical therapy evaluation states you are dependent for rolling, sitting up, lying down, standing up, and for bed/chair transfers. The occupational therapy evaluation states you need assistance with bathing, eating, and oral hygiene. You have no skilled nursing needs. You have skilled therapy needs but do not need skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. 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 inpatient admission for the right reverse shoulder arthroplasty.

You asked the Plan to pre-approve inpatient admission. 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 inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation did not include any documented medical history or clinical circumstances which might warrant inpatient services before or after surgery to justify a hospital stay. There is no expectation from the documentation that the enrollee would require hospitalization that would cross two midnights. Therefore, the enrollee does not meet criteria for the requested inpatient stay. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for the right reverse shoulder arthroplasty.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 additional skilled nursing visits.

You asked the Plan to pre-approve 1 additional skilled nursing visit. You say that you are on 24-hour oxygen and your legs are swollen. You say that your oxygen level is being monitored every day and the help of a nurse coming in is a necessity. You say that your doctor advised that home services are needed for your betterment. The Plan denied your request. The Plan says you are medically stable and do not have any skilled nursing needs.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 1 additional skilled nursing visit. Our reviewer says that the 2 additional skilled nursing visits are not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee has skilled nursing needs. The reviewer found that the enrollee has had no medication changes. The reviewer found that the enrollee has near-by family and a paid caregiver to help him. Therefore, the reviewer found that ongoing home health skilled nursing services are not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 additional skilled nursing visit have not been met. Therefore, we decided that the Plan does not have to pre-approve 1 additional skilled nursing visits.
Appeal type: Practitioner Services
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 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 enrollee has a history of coronary artery disease, atrial fibrillation with rapid ventricular response and congestive heart failure decompensation with preserved ejection fraction. He has symptomatology of Class IV heart failure. The use of the CardioMEMs device in this instance remains experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OZURDEX (J7312).

You asked the Plan to pre-approve OZURDEX. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 OZURDEX. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found OZURDEX is a dexamethasone
intravitreal implant that is indicated in adults for the treatment of macular edema following branch retinal vein
occlusion or central retinal vein occlusion, diabetic macular edema in pseudophakic or phakic patients who are
planning to have cataract surgery, and for the treatment of non-infectious uveitis affecting the posterior
segment of the eye. In this case, the enrollee does not have any of these conditions and therefore the use is not
supported by the Medicare compendia. There is no documentation to support the effectiveness of the requested
therapy for the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of OZURDEX have not been met. Therefore, we decided that the Plan does not
have to pre-approve OZURDEX (J7312).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that you will run out of trips, and will not be able
to receive needed services from your provider. The Plan denied your request. The Plan says your benefit only
allows 24 trips for this service.

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 trips per year.

We looked at your request, the records in the case file, and the rules. Once you have used 24 one-way trips, you
will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided
that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you need these compression stockings because you have swelling, numbness, and nerve problems. These stockings reduce swelling and prevent blood clots. The Plan denied your request. The Plan says the requested type of compression stocking is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pre-approve gradient compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin.

You asked the Plan to pre-approve Oxycontin. The Plan denied your request. The Plan says the medication
does not fall under the Part B benefit.

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 Oxycontin.

Benefits for Oxycontin 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: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device for the enrollee.

You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer device. You say that this procedure and device are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial because the case file lacked medical records. The Plan requested a reopen and provided the required medical records.

Our Medical Director looked at the case file and the records submitted with the reopen request. At issue is coverage for a Vertiflex Superion interspinous spacer device. The medical records show the enrollee is a 54-year-old woman with multilevel degenerative disc disease and mild to moderate spinal stenosis at the L2-3-4-5 levels. The enrollee failed to respond to epidural steroid injection. The Vertiflex Superion interspinous spacer device was requested. However, at this time, there is limited evidence that interspinous spacer devices can relieve symptoms of lumber spinal stenosis. However, high failure rates have been reported, with pain, device migration, and spine fracture. Laminotomy decompression is the gold standard treatment for stenosis. There is insufficient literature to demonstrate the same or better results with interspinous spacer devices. Investigational or experimental services and devices are not covered by Medicare; therefore, this request should not have been approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total parenteral nutrition.

You asked the Plan to pre-approve total parenteral nutrition. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that parenteral nutrition is considered reasonable and
necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of
sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.

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 total parenteral nutrition. Our reviewer
says that the services are not medically necessary. Our physician reviewer found in this case, the
documentation provided does not indicate that you have a alimentary tract pathology that precludes the
absorption of sufficient nutrients through direct feeding of the alimentary tract by methods such as a feeding
tube.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of total parenteral nutrition have not been met. Therefore, we decided that the Plan
does not have to pre-approve total parenteral nutrition.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transvenous phrenic nerve stimulation.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare does not provide coverage of transvenous phrenic nerve stimulation for central sleep apnea.

The Plan must follow Medicare rules. Medicare rules say that Medicare will not provide coverage of transvenous phrenic nerve stimulation for central sleep apnea. 

We looked at the file and Medicare rules. There is currently insufficient evidence to show transvenous phrenic neurostimulation is reasonable and necessary for the treatment of illness. 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 transvenous phrenic nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.