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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 4, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that there was never any mention of an additional charge if a polyp was found and removed. You say that this was a routine procedure and you assumed you would be charged the normal $30 copayment. 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 $150 copayment for each in-network, Medicare- covered ambulatory surgical center visit. You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show a polyp was removed which is considered a surgical procedure. 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 colonoscopy provided on November 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. 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 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications and insulin. You had stable vital signs. You required supervision to modified independence level for transfers. You required varying assistance with activities of daily living. The documentation does not support that you require the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that you meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit.

You asked the Plan to waive the copayment for the outpatient clinic visits. You say that the surgery has a 90 global period therefore your follow up visits should be inclusive. You say that the copayment charges are an error. The Plan denied your request. The Plan says the copayments 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 $20 copayment for all other in-network, Medicare- covered outpatient hospital services.

You have been asked to pay a $20 copayment for each outpatient clinic visit. The total amount you owe is $40 ($20/visit x 2 visits = $40). The outpatient clinic visits fall within the "Outpatient hospital services" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure. 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 outpatient clinic visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described 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 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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says 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 Synvisc-One. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation indicating that the plan's required drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive eye exam provided on October 23, 2019.
You asked the Plan to pay for a comprehensive eye exam provided on October 23, 2019. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says comprehensive eye exams are only covered at no charge once annually. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information stating the services provided on October 23, 2019 were the second comprehensive vision exam for the year, as this exam was also provided on April 8, 2019.
The Plan is correct in this case. Medicare does not cover routine vision and eyewear services. The Plan offered a routine vision and eyewear benefit that exceeded Medicare coverage. For that reason, the Plan's 2019 coverage rules apply in this case. The 2019 Plan contract covers one comprehensive eye exam per year at no charge. The Plan submitted records to show you had a comprehensive exam on April 8, 2019. There was no charge for that exam. However, that exhausted that benefit for 2019. Therefore, the exam you had on October 23, 2019, was appropriately charged based on the Plan contract rules. Therefore, we decided that the Plan does not have to pay for the comprehensive eye exam provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 extractions (D7140), a complete upper denture
(D5110), and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you contacted the health plan and were told
that the services were covered. You say that you are in pain. You also say that you need to get some teeth
pulled. The Plan denied your request. The Plan says extractions are not listed as a covered service. The Plan
also says that dentures are not covered services either.
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 pre-approve 8
extractions (D7140), a complete upper denture (D5110), and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom artificial breasts identified with code L8035 and L8039.
You asked the Plan to pre-approve custom artificial breasts. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is billed, it 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 custom artificial breasts have not been met. Therefore, we decided that the Plan does not have to pre-approve custom artificial breasts identified with code L8035 and L8039.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) requested on March 16, 2021.
You asked the Plan to pre-approve the SNF admission. You say that these services are medically necessary. The Plan denied your request. The Plan says that SNF care cannot be covered after September 27, 2020 because you have used the 100-day benefit with no breaks of 60 days or more of inpatient care.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan's denial was that you had exhausted your maximum 100 days of SNF care within the benefit period. However, the file did not include evidence of when the covered days were received or evidence to support that you did not have a period of 60 days without inpatient care. As such, we cannot confirm that the denial is appropriate in this case. The Plan must approve this care until proper notice is issued. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) requested on March 16, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says per CMS guidelines, the documentation is lacking intensity of medical management needs and it appears therapy could be provided at lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a tibial fracture. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that Keytruda affected the enrollee's red blood cell production. The Plan denied your request. The Plan says the drug is not being required for a medically accepted standard.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Retacrit. Our physician reviewer found that the enrollee has a history of renal cell carcinoma and monoclonal gammopathy of unknown significance who has received Keytruda for chemotherapy. In this case, the drug is being requested to treat anemia in an enrollee who received myelosuppressive chemotherapy. The requested use is not an FDA approved indication. The last dose of chemotherapy was in September 2020. The enrollee is being treated with blood transfusion. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pay for drug testing (G0483) provided on August 11, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on January 16, 2020.
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says the member was not in Skilled Nursing Facility as a result provider should bill POS 32 for the services to be covered
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A Skilled Nursing Facility (SNF) stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray have not been met. This claim was billed with place of service code 31 indicating that the member was in a Part A SNF stay. Of note, if the member was not in a Part A covered stay, a more appropriate place of service code is required. Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac stress testing (78452).
You asked the Plan to pre-approve the cardiac stress testing. You say that the test is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that cardiac stress testing in asymptomatic patients is considered not reasonably 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 the cardiac stress testing. Our reviewer says that the requested cardiac testing is not medically necessary. Our physician reviewer found the enrollee has no history of Coronary Artery Disease, no anginal symptoms noted, and the last electrocardiogram showed normal sinus rhythm. The enrollee has no symptoms which would make the cardiac stress test 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 the cardiac stress testing have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac stress testing (78452).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.
You asked the Plan to pre-approve a home health aide.. You say that you cannot afford the care that you require. You say that it was covered before the plan pulled the plug. You say that you require peri care and bowl program. You also say that you were not given 30 days' notice. The Plan denied your request. The Plan says the home health aide services that were ordered do not meet the criteria for coverage. The Plan says that the requested care can be done safely and reasonably without professional skills and/or training.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says that a home health aide is not medically necessary. Our physician reviewer found the limited documentation that was provided does not show that you have documented skilled nursing needs. The reviewer found that you do not have documented skilled therapy needs either. Therefore, the reviewer found that a home health aide is 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 a home health aide. have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5%.

You asked the Plan to pre-approve Xiidra. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra 5%.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on July 23, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis. You say that you believe this service should be covered. The Plan denied your request. The Plan says the total $73 amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on July 23, 2020 by an OON provider.