Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2020. 
 
You asked the Plan to pay for the services provided. You say that the provider is recognized by Medicare as a 
nurse practitioner. The Plan denied your request. The Plan says a registered nurse is not a provider eligible for 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that collaboration is to be evidenced by NPs 
documenting their scope of practice and indicating the relationships that they have with physicians to deal with 
issues outside their scope of practice. 
 
We looked at the file and the rules. The records do not indicate the nurse practitioner services were performed 
in collaboration with a physician. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on 
April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on September 22, 
2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were not informed that you would 
owe a $275 copayment. 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 a $275 
copayment for advanced imaging services for outpatient hospital services.  
 
You have been asked to pay a $275 copayment for a CT scan. A CT scan falls within the outpatient hospital 
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 copayment for a CT scan provided on 
September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional acupuncture services. 
 
You asked the Plan to pre-approve additional acupuncture services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 additional acupuncture services.. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had tried 
acupuncture for 3 sessions with only short-term (3-4 days) benefit before pain coming back. There was no 
measurable and consistent improvement in overall chronic function related to this treatment modality to 
support ongoing regular use. Therefore, the enrollee does not meet criteria for the requested 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 additional acupuncture services. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 additional acupuncture services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Pegfilgrastim (Neulasta). 
 
You asked the Plan to pre-approve Neulasta. You say that the enrollee needs this drug as soon as possible. The 
Plan denied your request. The Plan says that the drug/regimen is not being prescribed for a medically-accepted 
indication. 
 
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 Neulasta. Our reviewer says that 
Neulasta is medically reasonable and necessary for the enrollee. Our physician reviewer found the requested 
use of Neulasta is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use of Neulasta 
is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. It is considered for use in neutropenic patients with recurrent or resistant infections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Pegfilgrastim (Neulasta).  
 
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: Drugs
Decision: Favorable

We decided that the Plan does not have to provide coverage for a Freestyle Libre 14 Day Sensor Kit (continuous glucose monitor (CGM)).
You asked the Plan to provide coverage for a CGM. You say this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial due to a lack of medical records from your physician. The Plan requested a reopen and provided additional information from your physician, who confirmed you do not meet the required criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when all of the criteria listed above are met. The Plan has confirmed that your ordering physician acknowledges that you do not meet all of the required criteria for this equipment but states it would be beneficial for your use. While this equipment may be beneficial for your use, Medicare does not cover this equipment unless all of the required criteria are documented as met by your ordering physician. Therefore, we decided that the Plan does not have to provide coverage for a Freestyle Libre 14 Day Sensor Kit (continuous glucose monitor).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit rendered on September 26, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure code 99204 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99204 is new patient office or other outpatient visit, typically 45 minutes.We find that CPT code 99204 is not supported in the medical record. Specifically, the code is for a new patient office visit and the documentation shows that you were previously seen by this provider on May 26, 2020; therefore, a new patient office visit does not apply. 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 pay forthe office visit rendered on September 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided on September 14, 2020. 
 
You asked the Plan to pay for the eyewear. You say that you were instructed by the doctor's office to submit a 
letter and a copy of the receipt. The Plan denied your request. The Plan says the use of an out-of-network 
provider for your vision wear will not be reimbursed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The provider in this case is not an in-network provider. Based on this 
information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the eyewear provided on September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 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 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 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. Our reviewer found that 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on July 20, 2020. 
 
You asked the Plan to pay for the services provided. You say that monitored anesthesia care is medically 
necessary due to comorbidities. The Plan denied your request. The Plan says the use of general anesthesia for 
routine pain procedures is warranted only in unusual circumstances. 
 
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. In this case, there are insufficient medical records to clearly establish 
the need for sedation for the provided procedure. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on May 24, 
2019. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because 
you did not receive proper notice of the member's benefit determination. The Plan denied your request. The 
Plan says this claim was filed outside the twelve months allowed for claim submissions. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychotherapy services was not filed until September 3, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on 
May 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 28, 2019.You asked the Plan to pay forthe services provided. You say that you depend on the facility for timely notification of the enrollee's insurance coverage.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until August 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on March 28, 2019
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on July 13, 2020 
 
You asked the Plan to waive the copayment for an x-ray. You say that you shouldn't be billed for this because 
so much time has passed and you paid your office visit copayment. The Plan denied your request. The Plan 
says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for outpatient diagnostic tests/x-ray.  
 
You have been asked to pay $42.30 which is less than your copayment amount of $45 copayment for an x-ray. 
An x-ray falls within the outpatient diagnostic tests/x-ray 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 an x-ray provided by a participating provider on July 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient services. You say that you would like reconsideration because this was a follow-up visit.The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would requirethe Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) provided
on January 23, 2019.
You asked the Plan to waive the copay for the MRI. You say that this is a steep copay for the test. The Plan
denied your request.
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 $250
copay for advanced imaging services.
You have been asked to pay $240.04 for the MRI. Because the amount is less than the $250 copay, you were
charged the lesser amount. The MRI falls within the outpatient diagnostic tests 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 magnetic resonance imaging (MRI) provided on January 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the periapical x-ray 
(D0220), and the topical application of fluoride varnish (D1206) provided on August 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services you received were necessary. The 
Plan denied your request. The Plan says periodic oral exams and emergency exams share a frequency limit of 
two procedures per calendar year. The Plan says that one periapical x-ray is covered per calendar year. The 
Plan says two fluoride applications are covered per calendar year. The Plan also says that the frequency limits 
for these services have 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, the frequency limits of two periodic or 
emergency exams per calendar year has been exceeded. The record shows that the Plan paid for emergency 
exams that you received on January 7, 2020, and March 18, 2020. The frequency limit of one periapical x-ray 
per calendar year has been exceeded. The record shows that the Plan paid for a periapical x-ray that you 
received on March 18, 2020. The frequency limit of two fluoride applications per calendar year has been 
exceeded. The record shows that the Plan paid for the fluoride application that you received on February 6, 
2020, and May 20, 2020. Therefore, we decided that the Plan does not have to pay for the periodic oral 
evaluation (D0120), the periapical x-ray (D0220), and the topical application of fluoride varnish (D1206) 
provided on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs critical illness recovery hospital services to continue her plan of care.The Plan denied your request. The Plan says criteria for admission to the LTACH 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveLTACH services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that this enrollee's clinical condition meets full inpatient acute rehab criteria.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to acute inpatient rehabilitation.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 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. Our reviewer found that 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that 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-approveacute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SNF admission.You asked the Plan to pre-approvethe SNF admission. You say that you are not fit to be discharged home.The Plan denied your request. The Plan says your request for approval of admission to a SNF from an inpatient rehabilitation facility does not meet the requirements for approval.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewersays that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvea SNF admission.