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

We decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0364), a core buildup (D2920), and a consultation (D9310), and does not have to pay an additional amount for endodontic therapy (D3330) provided on March 1, 2021.

You asked the Plan to pay for a cone beam computed tomography capture and interpretation, a core buildup, a consultation, and to pay an additional amount for endodontic therapy. You say that you were not aware that the services would not be covered. The Plan denied your request. The Plan says the cone beam computed tomography capture and interpretation, a core buildup, and a consultation are not covered services. The endodontic therapy was paid at the Medicare allowed rate therefore no additional payment can be made. 

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 cone beam computed tomography capture and interpretation, a core buildup, and a consultation are not among those covered under this benefit. Additionally, the allowed amount for the endodontic therapy for an out-of-network provider was paid by the plan. Therefore, we decided that the Plan does not have to pay for a cone beam computed tomography capture and interpretation (D0364), a core buildup (D2920), a consultation (D9310), and does not have to pay an additional amount for endodontic therapy (D3330) provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. 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 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation does not support that the enrollee performs blood 
glucose testing at least four times per day, uses insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. 

Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care for the enrollee.

You asked the Plan to provide coverage for acute inpatient hospital care. You say that inpatient admission is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for inpatient care
were not met. Maximus overturned the Plans denial for inpatient admission. The Plan requested a reopen and
stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an inpatient
admission. The Maximus Physician Reviewer determined that inpatient hospital services were medically
necessary and reasonable for this enrollee. The Plan argues the enrollee could be initially monitored within the
ambulatory/observation setting and changed to inpatient status based upon any operative or post-operative
concerns.

The medical records show the enrollee is a 66-year-old man with a medical history of DVT, hypertension, and
sleep apnea. The enrollee was to undergo right shoulder arthroplasty. Our Medial Director has concluded that
the Plan is correct in this case. The documentation does not support that at the time of inpatient admission, the
admitting physician reasonably expected that the patient's necessary hospital care would span two midnights.
Medicare 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantable neurostimulator coded as 64555 and L8679.

You asked the Plan to pre-approve the implantable neurostimulator. You say that the enrollee has tried and failed conservative care and medication therapies. Based on history and current diagnoses, the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says Medicare will not pay for an auricular stimulator device as it is an auricular peripheral nerve stimulation device.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implantable neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantable neurostimulator coded as 64555 and L8679.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 12, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that the enrollee needed a refill of his pain medications for his chronic pain. You also say that the services should be covered. The Plan denied your request. The Plan says prior authorization was not obtained prior to rendering the services. The Plan also says that the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit and before providing services to the enrollee.

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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician services 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 March 12, 2021 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab. 
 
You asked the Plan to pre-approve Rituximab. You say that the enrollee was previously on a Rituximab 
regimen. The Plan denied your request. The Plan says the preferred drug must be tried before Rituxan can be 
approved. 

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 looked at the file, and Medicare rules. The medical records provided do not show that the enrollee has tried 
and failed Truxima. The records do not show that the plan's required drug would likely be less effective or 
likely have adverse effects for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Rituximab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Savella tab 50mg.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this medication falls under Part D coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Savella tab 50mg.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 in this case, the enrollee was admitted with hypoxic respiratory failure due to pneumonia and tracheostomy failure form mucous plugs. The enrollee is receiving antibiotic therapy and wound care. The record indicates that the enrollee remains agitated and required additional dialysis due to fluid overload. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with an out-of-network rheumatologist.

You asked the Plan to pre-approve out-of-network office visits. The Plan denied your request. The Plan says in-network providers are available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits with an out-of-network rheumatologist.
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 IRF admission is medically necessary The Plan denied your request. The Plan says the medical records do not show that the enrollee requires IRF 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. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network
provider.

You asked the Plan to pre-approve out-of-network massage therapy. You say that you have been treated by this
massage therapist before and have a trusting relationship. You say that you have never experienced a more
effective massage and it provided the relief you needed. The Plan denied your request. The Plan says innetwork
providers are available.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home phototherapy device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's skin disease is having a 
significant impact on her life. The Plan denied your request. The Plan says there is no documented history of 
diagnosis or prior UVB treatment 
 
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 requested device. Our physician 
reviewer found that in this case, the record indicates that the enrollee has pruritus and dermatitis from prurigo 
nodularis. The record indicates that the enrollee has been treated with steroids, duoderm with responsiveness, 
but then returns within 3-4 days. The record does not indicate that UV therapy has been tried previously.  
Based upon the totality of the record, home phototherapy is not medically necessary or reasonable, as defined 
by Medicare rues, 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home phototherapy device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tubal ligation.

You asked the Plan to pre-approve tubal ligation. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that tubal ligation is not covered if the primary indication for the procedure is sterilization. 

We looked at the file and Medicare rules. In this case, sterilization is the primary purpose of the requested tubal ligation. This is not a covered indication. Based on this information, we decided that Medicare rules for coverage of tubal ligation have not been met. Therefore, we decided that the Plan does not have to pre-approve tubal ligation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam computed tomography (CT) capture and interpretation with field of view of one full dental arch (D0365), the apicoectomy (D03421), and the retrograde filling (D3430) provided on September 14, 2020.

You asked the Plan to pay for the cone beam CT. You say that the root canal was completed but your insurance would not cover it. You say that the dentist should not have changed the procedure without consulting you. You also say that you were lied to by the plan and the dentist, and you are not going to pay your bill. The Plan denied your request. The Plan says the cone beam CT is not listed as a covered service.

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 cone beam computed tomography (CT) capture and interpretation with field of view of one full dental arch (D0365), the apicoectomy (D03421), and the retrograde filling (D3430) provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided form November 25, 2020, to February 25, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were not informed that the provider was out-of-network and would not have agreed to the device had you known. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 20% coinsurance for DME and related supplies. 

You received DME and related supplies from November 25, 2020, to February 25, 2021 for a total of 4 services. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the provided chart.

The total amount you owe is: $2,342.82. 

You have been asked to pay the total coinsurance amount of $2,342.82 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided form November 25, 2020, to February 25, 2021.
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 the admission to an IRF is medically necessary. The Plan denied your request. The Plan says the admission to an IRF is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 does not require an intensive rehabilitation therapy program. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the member meets criteria for LTACH services. The Plan denied your request. The Plan says that the enrollee's illness is not complex enough to require daily physician management and the enrollee does not require specialized nursing services that are only available in an LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint (27096) to be
provided by an out of network (OON) provider.

You asked the Plan to pre-approve the injection procedure for sacroiliac joint. You say that this requested
procedure is medically necessary for the enrollee's severe pain. The Plan denied your request. The Plan says
they have in-network providers available to perform the requested services.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the injection procedure for sacroiliac joint (27096) to be provided by an out of network (OON) provider.