Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission criteria. The Plan denied your request. The Plan says the requested LTACH services are 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 that the enrollee is not clinically stable. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that the enrollee is not currently receiving that would be available at the LTACH.

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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
November 6, 2019, through November 8, 2019.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the services do not meet medical necessity for inpatient and could be performed in an outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was admitted on November 6, 2019 for a left ankle arthroscopy for treatment of post-traumatic arthritis/malunion left ankle. The enrollee's records show that the enrollee did not require postoperative care beyond 48 hours. The procedure should be performed as an outpatient procedure per Milliman Clinical Guidelines (MCG) S-72 for ankle arthroscopy. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 6, 2019, through November 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during arthroscopy services coded 29880 and G0289 provided on November 5, 2020.

You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during arthroscopy services coded 29880 and G0289 provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on March 3, 2021.

You asked the Plan to waive the copay for the specialist visit. You say that the provider said it should be covered. The Plan denied your request. The Plan says the claim processed 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 $40 copay for each specialist visit. 

You have been asked to pay a $40 copay for the specialist visit. The specialist visit falls within the physician services 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 copay for the specialist office visit provided on March 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from SNF care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to provide coverage for transfer to an LTACH. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for this transfer are not met. Maximus overturned the Plans denial administratively because medical records were not included in the case file for review. The Plan requested a reopen and provided the required medical records.
Our Medical director looked at the case file and the reopen request. At issue is coverage for admission to a long-term acute care hospital (LTACH). The medical records show the enrollee to be an 82-year-old woman for whom admission to a long-term acute care hospital (LTACH) has been requested. At issue is whether LTACH services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee's past medical history is notable for heart disease, COPD, diabetes, obesity, and chronic kidney disease.
The enrollee was admitted to the acute care hospital with worsening cellulitis of her bilateral lower extremities. The enrollee has multiple lower extremity wounds. The enrollee developed likely pneumonia in the upper lobes. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is/was receiving acute hospital care, and acute care services were not denied. The documentation does not support that the enrollee in this case required services at the LTACH that were not available at the acute care hospital where she was receiving care. The documentation does not support that the requested LTACH services were medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to provide coverage for transfer to long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided to the enrollee from September 11, 2020, to September 12, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.
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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 68-year-old male with a history of stage IV lung cancer arriving to the emergency department via ambulance with altered mental status at the skilled nursing facility. He was diagnosed and treated for UTI, hypercalcemia and hypokalemia with calcitonin, potassium, and antibiotics and seen on September 11, 2020, by the attending physician. The enrollee was found to be hemodynamically stable. There was no documentation found stating that the enrollee was not stable at any point in the course of care. The records show that approximately at 3:33 pm on September 11, 2020, the enrollee was stable for transfer to another facility. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided to the enrollee from September 11, 2020, to September 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the elbow x-ray rendered on February 24, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for diagnostic procedures and tests at an in-network outpatient hospital.
Review of the file shows that you received an elbow x-ray on February 24, 2021. You have been asked to pay a $90 copayment for these services. These services fall within the diagnostic procedures and tests at an in-network outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the elbow x-ray rendered on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on October 23, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
The file shows that a knee brace and suspension sleeve were provided. We looked at the file and Medicare rules. In this case, the record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on October 23, 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 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 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 you were admitted to an acute care hospital for E coli sepsis and was discharged home on May 1, 2021. There is ongoing weakness. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says that further research is needed for the use of rituximab in the treatment of membranous nephropathy.
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 Rituxan. Our physician reviewer found that the enrollee has diffuse membranous glomerulonephritis. The requested use of Rituxan is not FDA-approved for the enrollee's diagnosis. However, the use is supported by one of the major drug compendia, Lexicomp. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does 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 Rituxan have been met. Therefore, we decided that the Plan has to pre-approve Rituxan.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mouth guard (D9944) provided on March 11, 2021.
You asked the Plan to pay for the mouth guard. You say that this item is necessary for your jaw. The Plan denied your request. The Plan says this item is not covered by the dental 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 mouth guard (D9944) provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint provided on January 26, 2021.
You asked the Plan to pay for the RFA. The Plan denied your request. The Plan says this is an experimental procedure.
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 RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the procedure was not medically reasonable or 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 RFA have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on January 20, 2021.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says services must be performed by the Plan's vision provider in order to receive payment for routine vision hardware.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan's vision provider is used. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and three additional intraoral periapical x-rays provided on December 15, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were not informed about how many x-rays you were able to receive. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitation has been exceeded.
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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on March 10, 2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have
to pay for the first intraoral periapical x-ray and three additional intraoral periapical x-rays provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, and armrests with gel pads.
You asked the Plan to pre-approve expandable controller, harness, and armrests with gel pads. You say that you need these components. The Plan denied your request. The Plan says the denial of authorization for these power wheelchair components is correct, because the records do not show a need for these items.
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 expandable controller, harness, and armrests with gel pads. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices or non-proportional input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. Your strength and function in the upper extremities indicate that you can control any power options through their own individual switches. You were already approved for armrests included in the tilt and recline system, so the separate armrests with gel pads exceed your medical needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller, harness, and armrests with gel pads have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and armrests with gel pads.