Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc for the enrollee.

You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied your request. The Plan says the Step Therapy criteria were not met. Maximus overturned the Plans denial for lack of medical records. The Plan requested a reopen and provided additional medical records.

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. Our Medical Director looked at the case file and the reopen request. At issue is coverage for Orthovisc (Hyaluronic acid). Maximus determined that without medical records, we could not substantiate the Plans position. The Plan requested a reopen and provided the required medical records. The enrollee has a diagnosis of bilateral osteoarthritis of the knees, with pain in both knees. The Plan requires a trial of Synvisc One and Euflexxa before they will approve the requested drug. The documentation does not support that Synvisc-One and Euflexxa have been tried and failed. The documentation does not support that Synvisc One and Euflexxa would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the required coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

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 a portable oxygen concentrator. Our reviewer says that the documentation does not support that the requested portable oxygen concentrator is medically reasonable or necessary. Our physician reviewer found the enrollee has already been supplied with a portable oxygen system. Medicare covers a portable oxygen system when necessary but does not specify what kind of system. Medicare does not cover portable systems specifically for travel outside the home. The medical records do not document the need for a portable oxygen concentrator for mobility within the home. Therefore, the enrollee does not meet criteria for the requested item.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (95999) provided on July 16, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled procedure.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. We looked at the file and Medicare rules. The requested Train of Four testing is considered a bundled procedure and is not separately payable. Payment for this service is included in the payment for the procedure itself. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (95999) provided on July 16, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that an extended stay is medically necessary. The Plan denied your request. The Plan says the enrollee no longer has skilled needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or therapy needs. The enrollee is ambulating and tending to activities of daily living with independence or minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and can be provided 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that the enrollee requires SNF services for continued safety, nursing care, and rehabilitation. The Plan denied your request. The Plan says the enrollee can receive appropriate services at the IRF until ready to safely return home.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee has reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549 for the enrollee.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered because it does not meet the statutory definition of a dressing.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 compression stockings identified with code A6549 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional splinting (D4321), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), the therapeutic parenteral drug (D9612), the bone graft at time of implant placement (D6104 x 2), the surgical extraction (D7210 x 2), and the unspecified adjunctive service (D9999 x 2) provided from November 2, 2020, to November 10, 2020.
You asked the Plan to pay for the dental services. You say that you received a bill for $401.55. You also say that the services should be covered. The Plan denied your request. The Plan says the dental services that you received are not listed as covered services. The Plan also says that any services not listed are not covered.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the provisional splinting (D4321), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), the therapeutic parenteral drug (D9612), the bone graft at time of implant placement (D6104 x 2), the surgical extraction (D7210 x 2), and the unspecified adjunctive service (D9999 x 2) provided from November 2, 2020, to November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on April 24, 2020.
You asked the Plan to waive the coinsurance for a walker. You say that you were told that you would not owe anything. The Plan denied your request. The Plan says the correct coinsurance has been 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% coinsurance for durable medical equipment/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for a walker. The total allowed amount is $107.66. The total amount you are being asked to pay is $21.53 ($107.66 x 20% = $21.53). A walker falls within the durable medical equipment/in-network 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 coinsurance for durable medical equipment provided by a participating provider on April 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says this is only approved through February 19, 2021.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have COPD according to the medical record, although there are no pulmonary function test results. There is no documentation of C02 retention, or failure of BiPAP. The ventilator was apparently prescribed but the circumstances and reasons are not provided. The only clinical note in the record is a pulmonary visit and there is no mention of a ventilator.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, cervical (72040) provided December 15, 2020.
You asked the Plan to pay for the x-ray services. You say that you are appealing you having to pay for the x-ray services from the chiropractor. You don't understand how he can find out the problem unless he has something to see where the problem is. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the radiologic examination, spine, cervical (72040) provided December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device for the
enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there has been no trial and failure with a basic device.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation indicates that the enrollee had only a 30-minute trial of an E0651 device. There is no
documentation that the edema extends to the trunk, chest or abdomen.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Flexitouch pneumatic compression device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex Superion device. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Transcatheter mitral valve replacement (TMVR) with an Edwards Sapien Valve (0484T) for the enrollee.

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 that that this is only able to be covered if the patient is enrolled in a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 requested services are considered medically reasonable and necessary in this case. The patient has an absolute clinical indication for mitral valve replacement based on his clinical condition. The transcatheter valve replacement procedure is not investigational as the Sapiens 3 mitral valve has been approved by the FDA for this specific indication of replacement for "valve in valve" use in patients at high risk for open surgical valve replacement as determined by a multidisciplinary heart team as is the case in the circumstance. There is also published data with extended follow-up to recommend it for mitral "valve in valve" procedures such as this one. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Transcatheter mitral valve replacement (TMVR) with an Edwards Sapien Valve (0484T) for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on September 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided 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 services provided to the enrollee by an out-of-network provider on September 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
from May 11, 2020, to May 31, 2020.
You asked the Plan to waive the copayment for SNF care. You say that these services should be covered
because the enrollee had COVID-19. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for Skilled
Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $6,700 for 2020. At the
time this claim was processed, $3,326.44 of the $6,700 in-network maximum out-of-pocket amount had been
met. This SNF stay lasted 21 days, which were days 5 to 25 of the benefit period, resulting in a total copayment
amount of $373.56 because this amount, along with other cost-sharing amounts the enrollee has been asked to
pay, met the $6,700 in-network maximum out-of-pocket amount for 2020.
The enrollee has been asked to pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for
days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
from May 11, 2020, to May 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 28, 2020.
You asked the Plan to pay for knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says the patient did not receive video or telephonic visit by ordering physician in order to warrant the codes billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section. 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 knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided September 28, 2020.