Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two bone replacement grafts for ridge preservations
provided on January 30, 2020.
You asked the Plan to pay for the bone replacement grafts. You say that you had an extraction of two broken
molars. You also say that you would not qualify this as surgery. The Plan denied your request. The Plan says
this service is not a covered benefit.
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 two
bone replacement grafts for ridge preservations provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing the Plan's denial of the requested orthotics. You say that your leg is two inches shorter than the other which causes improper balance. You stated that you cannot walk without proper balance and asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 3, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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, rest home visit provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD). 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 item is not covered. The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care. You asked the Plan to pre-approve a home visit for assistance with activities of daily living and personal care. The Plan denied your request. The Plan says you do not meet the coverage criteria: (bedridden, stroke, congestive heart failure, chronic obstructive pulmonary). The contract with the Plan says that the Plan covers In-home Support Services for enrollee's who meet certain criteria such as: bedridden, stroke, congestive heart failure (stage 3 and 4), chronic obstructive pulmonary (stage 3 and 4). We looked at the file and the Plan's rules. The file shows that you do not meet the Plan's coverage criteria. Therefore, we decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary to help manage medications. The Plan denied your request. The Plan says this is not medically necessary.
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 the visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. Skilled nursing services are not required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. You do not have complex wound care, a need for IV antibiotics, new enteral feedings. You have had extensive prior SN treatment and should be educated in disease management. Your needs do not require ongoing skilled nursing 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 the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool or bench.You asked the Plan to pre-approve a tub stool. The Plan denied your request. The Plan says the item does not serve a purpose that is primarily medical in nature.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vitamin B-12 injection services provided to the enrollee on June 19, 2019. You asked the Plan to pay for the services. You say that the enrollee's condition met all the requirements for the need to have this procedure done.The Plan denied your request. The Plan says experimental or investigational services are not covered. 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 services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee has diagnoses of low back pain and muscle spasms and was treated with an injection of Vitamin B12 on 6/19/19. Review of compendia does not support the used of this treatment for the enrollee's stated conditions. Without the suppport of the compendia, medical necessity cannot be determined. 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 vitamin B-12 injection services provided to the enrollee on June 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided
from August 9, 2018 through August 18, 2018.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that rehabilitation
services has a $0 copayment for days 1-20. You say that the hospital wasn't supposed to charge a copayment
for rehabilitation. The Plan denied your request. The Plan says the copayment 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 $335
copayment each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days. Your contract with the Plan clearly says that for inpatient hospital care, the costsharing
described above applies each time you are admitted to the hospital. A transfer to a separate facility type
(such as an Inpatient Rehabilitation Hospital or Long Term Care Hospital) is considered a new admission.
You have been asked to pay a $1,675 copayment for the inpatient rehabilitation stay. ($335/day x 5 days =
$1,675). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" benefit category. The
records show that you were transferred to inpatient rehabilitation on August 9, 2018.
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 rehabilitation stay provided from August 9,
2018 through August 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 2, 2019 by an out of network (OON) provider. You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 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 physician services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis provided on September 4, 2019.
You asked the Plan to pay for the knee orthosis. 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
knee orthosis. We found no exception that would require the Plan to pay for this item. Therefore, we decided
that the Plan does not have to pay for a knee orthosis provided on September 4, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has generalized weakness and difficulty walking. She has
received physical therapy with benefit. Her symptoms have improved and she needs assistance with care.
While the requested services are generally accepted as specific and effective therapy for the enrollee's
condition, the records do not show that she requires the unique skills of a professional therapist to safely and
effectively provide care. She has no residual deficits that could not be addressed by a home exercise program.
The requested services are therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued physical therapy.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the medical services provided on January 13, 2020.
You asked the Plan to pay for the services provided. You say that additional reimbursement is owed. The Plan denied your request. The Plan says that the diagnosis code is not listed as supporting medical necessity.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The documentation in the case file does not include the claim at issue, or an explanation of benefits indicating what services have been denied. MAXIMUS requested additional information from the Plan, with no response. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the medical services provided on January 13, 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 you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on June 2, 2020 and underwent treatment for a blood clot. You are medically stable as of June 8, 2020. You are able to walk 90 feet with a walker and need varied assistance with activities of daily living. You have no complex medical, nursing, or rehabilitation needs that require supervision by physical medicine and rehabilitation or acute rehab nursing. You may benefit from further therapy but do not require an intensive therapy program 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 pay for post-stabilization inpatient care provided November 22 to November 24, 2019. You asked the Plan to pay for the post-stabilization inpatient care. You say that the inpatient care was medically necessary and should be covered. The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization inpatient care. Our reviewer says that coverage criteria was not met. Our physician reviewer found the record shows the enrollee was stable for transfer to an in-network facility via ambulance after the initial emergency 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 the post-stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient care provided November 22 to November 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.
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 you were medically stable, with no evidence of a need for supervision by a PMY physician, or a need for acute rehab nursing care. Functionally, given that you only need minimum assist, you do not need the IRF admission. You may benefit from further PT and OT, but you do not require an intensive therapy program. The admission is not medically necessary based on your current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix for the enrollee.
You asked the Plan to pre-approve Vectibix. The Plan denied your request. The Plan says that this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Vectibix. Our reviewer says that Vectibix is not medically reasonable and necessary for the enrollee in this case. The drug is not FDA approved for KRAS mutated rectal cancer. The drug is not supported in any of the CMS compendia for use in KRAS mutated rectal cancer. This reviewer did not find any supportive citations in a PubMed search. The use is not listed as indicated, supported or recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Vectibix. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have to pre-approve Vectibix for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services needed could be provided in another setting, such as an acute
rehab facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 the enrollee does not meet the criteria for a LTACH. There is no specific service that
is offered by an LTACH for this enrollee that cannot be offered in another facility. At present the enrollee is
too unstable for discharge from acute care setting. There are no specific needs that would require LTACH
services are identified.
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 admission to a long term acute care hospital (LTACH) for the enrollee.